Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial

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.

Amyloid Deposition: An Unusual Case of Deep Gluteal Syndrome and Sciatic Nerve Compression: A Case Report

CASE

Soft-tissue amyloidomas are exceedingly rare, with only a few cases reported in the literature. There are no reports of sciatic nerve compression secondary to a soft-tissue amyloidoma. We report a unique case of a 71-year-old man with an incidentally found amyloidoma who was initially believed to have deep gluteal syndrome. He had a favorable outcome after surgical decompression.

CONCLUSION

For patients who do not have classic examination and electromyography/nerve conduction findings of piriformis syndrome, providers should explore other etiologies of peripheral nerve compression including soft-tissue amyloidoma.

The effect of surgeon-controlled variables on construct stiffness in lateral locked plating of distal femoral fractures

Background

Nonunion following treatment of supracondylar femur fractures with lateral locked plates (LLP) has been reported to be as high as 21 %. Implant related and surgeon-controlled variables have been postulated to contribute to nonunion by modulating fracture-fixation construct stiffness. The purpose of this study is to evaluate the effect of surgeon-controlled factors on stiffness when treating supracondylar femur fractures with LLPs:

Does plate length affect construct stiffness given the same plate material, fracture working length and type of screws?

Does screw type (bicortical locking versus bicortical nonlocking or unicortical locking) and number of screws affect construct stiffness given the same material, fracture working length, and plate length?

Does fracture working length affect construct stiffness given the same plate material, length and type of screws?

Does plate material (titanium versus stainless steel) affect construct stiffness given the same fracture working length, plate length, type and number of screws?

Methods

Mechanical study of simulated supracondylar femur fractures treated with LLPs of varying lengths, screw types, fractureworking lenghts, and plate/screw material. Overall construct stiffness was evaluated using an Instron hydraulic testing apparatus.

Results

Stiffness was 15 % higher comparing 13-hole to the 5-hole plates (995 N/mm849N vs. /mm, p = 0.003). The use of bicortical nonlocking screws decreased overall construct stiffness by 18 % compared to bicortical locking screws (808 N/mm vs. 995 N/mm, p = 0.0001). The type of screw (unicortical locking vs. bicortical locking) and the number of screws in the diaphysis (3 vs. 10) did not appear to significantly influence construct stiffness (p = 0.76, p = 0.24). Similarly, fracture working length (5.4 cm vs. 9.4 cm, p = 0.24), and implant type (titanium vs. stainless steel, p = 0.12) did also not appear to effect stiffness.

Discussion

Using shorter plates and using bicortical nonlocking screws (vs. bicortical locking screws) reduced overall construct stiffness. Using more screws, using unicortical locking screws, increasing fracture working length and varying plate material (titanium vs. stainless steel) does not appear to significantly alter construct stiffness. Surgeons can adjust plate length and screw types to affect overall fracture-fixation construct stiffness; however, the optimal stiffness to promote healing remains unknown.

The expansion and validation of a new upper extremity item bank for the Patient-Reported Outcomes Measurement Information System® (PROMIS)

Background

The Patient-Reported Outcomes Measurement Information System® (PROMIS) includes a Physical Function (PF) item bank and an Upper Extremity (UE) item bank, which is composed of a subset of items from the PF bank. The UE item bank has few items and known ceiling effects. Therefore, this study aimed to expand the item bank to assess a wider range of functioning. With the additional content, other psychometric properties—improved content validity, item bank depth, range of measurement, and score reliability—were also evaluated. We convened an expert panel to review potential items, and then conducted psychometric analyses on both extant and newly-collected data.

Results

Expert focus groups reviewed the PF item bank for items that were “sufficiently” related to upper extremity functioning for inclusion in the expanded UE item bank. The candidate item bank was quantitatively evaluated in a new sample of 600 people. The final items were calibrated in an aggregated dataset (n = 11,635) from two existing datasets, and the newly collected sample. The original UE item bank included 15 items. After expert review and quantitative evaluation, 31 items were added. The combined 46 items were calibrated using item response theory (IRT). Then computer adaptive tests (CATs) were simulated based off of the psychometric results. These indicated that the new UE item bank has an extended measurement range compared to the original version.

Conclusions

The expanded PROMIS UE item bank assesses a wider range of upper extremity functioning compared to the initial UE item bank. However, ceiling effects remain a concern for unimpaired groups. The new UE item bank is recommended for individuals with known or suspected upper extremity limitations.

Validation of PROMIS Physical Function Instruments in Patients With an Orthopaedic Trauma to a Lower Extremity

OBJECTIVES

To evaluate the reliability, convergent validity, known-groups validity, and responsiveness of the Patient-Reported Outcomes Measurement Information System (PROMIS) Mobility Computer Adaptive Test (CAT) and PROMIS Physical Function 8a Short Form.

DESIGN

Prospective cohort study.

SETTING

Two Level-I trauma centers.

PATIENTS

Eligible adults with an isolated lower extremity trauma injury receiving treatment were approached consecutively (n = 402 consented at time 1, median = 80 days after treatment). After 6 months, 122 (30.3%) completed another assessment.

INTERVENTION

Cross-sectional and longitudinal monitoring of patients.

MAIN OUTCOME MEASUREMENTS

Floor and ceiling effects, reliability (marginal reliability and Cronbach's alpha), convergent validity, known-groups discriminant validity (weight-bearing status and fracture severity), and responsiveness (Cohen's d effect size) were evaluated for the PROMIS Mobility CAT, PROMIS Physical Function 8a Short Form, and 5 other measures of physical function.

RESULTS

PROMIS PFSF8a and Foot and Ankle Ability Measure Activities of Daily Living Index had ceiling effects. Both PROMIS measures demonstrated excellent internal consistency reliability (mean marginal reliability 0.94 and 0.96; Cronbach's alpha = 0.96). Convergent validity was supported by high correlations with other measures of physical function (r = 0.70-0.87). Known-groups validity by weight-bearing status and fracture severity was supported as was responsiveness (Mobility CAT effect size = 0.81; Physical Function Short Form 8a = 0.88).

CONCLUSIONS

The PROMIS Mobility CAT and Physical Function 8a Short Form demonstrated reliability, convergent and known-groups discriminant validity, and responsiveness in a sample of patients with a lower extremity orthopaedic trauma injury.

AO Patient Outcomes Center: Design, Implementation, and Evaluation of a Software Application for the Collection of Patient-Reported Outcome Measures in Orthopedic Outpatient Clinics

BACKGROUND

Patient-reported outcomes are increasingly utilized in routine orthopedic clinical care. Computer adaptive tests (CATs) from the Patient-Reported Outcomes Measurement Information System (PROMIS) offer a brief and precise assessment that is well suited for collection within busy clinical environments. However, software apps that support the administration and scoring of CATs, provide immediate access to patient-reported outcome (PRO) scores, and minimize clinician burden are not widely available.

OBJECTIVE

Our objective was to design, implement, and test the feasibility and usability of a Web-based system for collecting CATs in orthopedic clinics.

METHODS

AO Patient Outcomes Center (AOPOC) was subjected to 2 rounds of testing. Alpha testing was conducted in 3 orthopedic clinics to evaluate ease of use and feasibility of integration in clinics. Patients completed an assessment of PROMIS CATs and a usability survey. Clinicians participated in a brief semistructured interview. Beta-phase testing evaluated system performance through load testing and usability of the updated version of AOPOC. In both rounds of testing, user satisfaction, bugs, change requests, and performance of PROMIS CATs were captured.

RESULTS

Patient feedback supported the ease of use in completing an assessment in AOPOC. Across both phases of testing, clinicians rated AOPOC as easy to use but noted difficulties in integrating a Web-based software application within their clinics. PROMIS CATs performed well; the default assessment of 2 CATs was completed quickly (mean 9.5 items) with a satisfactory range of measurement.

CONCLUSION

AOPOC was demonstrated to be an easy-to-learn and easy-to-use software application for patients and clinicians that can be integrated into orthopedic clinical care. The workflow disruption in integrating any type of PRO collection must be addressed if patients' voices are to be better integrated in clinical care.

Self-Reported Marijuana Use Is Associated with Increased Use of Prescription Opioids Following Traumatic Musculoskeletal Injury

BACKGROUND

Cannabinoids are among the psychoactive substances considered as alternatives to opioids for the alleviation of acute pain. We examined whether self-reported marijuana use was associated with decreased use of prescription opioids following traumatic musculoskeletal injury.

METHODS

Our analysis included 500 patients with a musculoskeletal injury who completed a survey about their marijuana use and were categorized as (1) never a user, (2) a prior user (but not during recovery), or (3) a user during recovery. Patients who used marijuana during recovery indicated whether marijuana helped their pain or reduced opioid use. Prescription opioid use was measured as (1) persistent opioid use, (2) total prescribed opioids, and (3) duration of opioid use. Persistent use was defined as the receipt of at least 1 opioid prescription within 90 days of injury and at least 1 additional prescription between 90 and 180 days. Total prescribed opioids were calculated as the total morphine milligram equivalents (MME) prescribed after injury. Duration of use was the interval between the first and last opioid prescription dates.

RESULTS

We found that 39.8% of patients reported never having used marijuana, 46.4% reported prior use but not during recovery, and 13.8% reported using marijuana during recovery. The estimated rate of persistent opioid use ranged from 17.6% to 25.9% and was not associated with marijuana use during recovery. Marijuana use during recovery was associated with increases in both total prescribed opioids (regression coefficient = 343 MME; 95% confidence interval [CI] = 87 to 600 MME; p = 0.029) and duration of use (coefficient = 12.5 days; 95% CI = 3.4 to 21.5 days; p = 0.027) compared with no previous use (never users). Among patients who reported that marijuana decreased their opioid use, marijuana use during recovery was associated with increased total prescribed opioids (p = 0.008) and duration of opioid use (p = 0.013) compared with never users.

CONCLUSIONS

Our data indicate that self-reported marijuana use during injury recovery was associated with an increased amount and duration of opioid use. This is in contrast to many patients' perception that the use of marijuana reduces their pain and therefore the amount of opioids used.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictors of Carpal Tunnel Release After Open Distal Radius Fracture

The purpose of this investigation was to determine the incidence and identify the predictors of carpal tunnel release (CTR) after open fractures of the distal radius (DRF). Patients with clinical symptoms of persistent median nerve neuropathy that required CTR were analyzed for risk factors. One hundred thirty-nine open DRFs (107 grade I, 23 grade II, 9 grade III) met the inclusion criteria. The incidence of CTR was 13.7% in all open DRFs (19 out of 139). Multivariable logistic regression analysis identified four predictors: male sex [odds ratio (OR) = 8.8, p = .001], type III Gustilo and Anderson grade (OR = 6.2, p = .04), OTA fracture type C (OR = 3.8, p = .03), and the application of external fixation (OR = 14.0, p D .02). The probability of CTR, determined by preoperative variables, was 80% with three factors present and 2% with no risk factors. High-risk patients may be identified who may benefit from closer perioperative surveillance and possibly carpal tunnel release. (Journal of Surgical Orthopaedic Advances 26(4):227-232, 2017).

Intra-articular dexamethasone to inhibit the development of post-traumatic osteoarthritis

Injury to the joint provokes a number of local pathophysiological changes, including synthesis of inflammatory cytokines, death of chondrocytes, breakdown of the extra-cellular matrix of cartilage, and reduced synthesis of matrix macromolecules. These processes combine to engender the subsequent development of post-traumatic osteoarthritis (PTOA). To prevent this from happening, it is necessary to inhibit these disparate responses to injury; given their heterogeneity, this is challenging. However, dexamethasone has the necessary pleiotropic properties required of a drug for this purpose. Using in vitro models, we have shown that low doses of dexamethasone sustain the synthesis of cartilage proteoglycans while inhibiting their breakdown after injurious compression in the presence or absence of inflammatory cytokines. Under these conditions, dexamethasone is non-toxic and maintains the viability of chondrocytes exposed chronically to such cytokines as interleukin (IL) -1, IL-6, and tumor necrosis factor-α. Moreover, the anti-inflammatory properties of dexamethasone have been appreciated for decades. In view of this information, we have initiated a pilot clinical study to determine whether a single, intra-articular injection of dexamethasone into the wrist shows promise in preventing PTOA after intra-articular fracture of the distal radius.

CLINICAL SIGNIFICANCE

Suppressing the various etiopathophysiological responses to injury in the joint is an attractive strategy for lowering the clinical burden of PTOA. The intra-articular administration of dexamethasone soon after injury offers a simple and inexpensive means of accomplishing this. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:406-411, 2017.

Interaction between living bone particles and rhBMP-2 in large segmental defect healing in the rat femur

Orthopedic surgeons sometimes combine recombinant, human BMP-2 with autograft bone when dealing with problematic osseous fractures. Although some case reports indicate success with this off-label strategy, there have been no randomized controlled trials. Moreover, a literature search revealed only one pre-clinical study and this was in a cranial defect model. The present project examined the consequences of combining BMP-2 with particles of living bone in a rat femoral defect model. Human bone particles were recovered with a reamer-irrigator-aspirator (RIA). To allow acceptance of the xenograft as surrogate autograft, rats were administered an immunosuppressive cocktail that does not interfere with bone healing. Implantation of 200 µg living bone particles generated a small amount of new bone and defects did not heal. Graded amounts of BMP-2 that alone provoked no healing (1.1 µg), borderline healing (5.5 µg), or full healing (11 µg) were added to this amount of bone particles. Addition of BMP-2 (1.1 µg) increased osteogenesis, and produced bridging in 2 of 7 defects. The combination of BMP-2 (5.5 µg) and bone particles made healing more reliable and advanced the maturation of the regenerate. Bone formation with BMP-2 (11 µg) and bone particles showed improved maturation. Thus, the combination of autograft and BMP-2 may be helpful clinically under conditions where the healing response is suboptimal. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:2137-2145, 2016. Clinical significance These data support the clinical use of recombinant, human BMP-2 with autograft bone when treating large segmental osseous defects. The combination leads to greater bone formation and accelerates the maturation of the regenerate.

Antimicrobial blue light inactivation of Candida albicans: In vitro and in vivo studies

Fungal infections are a common cause of morbidity, mortality and cost in critical care populations. The increasing emergence of antimicrobial resistance necessitates the development of new therapeutic approaches for fungal infections. In the present study, we investigated the effectiveness of an innovative approach, antimicrobial blue light (aBL), for inactivation of Candida albicans in vitro and in infected mouse burns. A bioluminescent strain of C. albicans was used. The susceptibilities to aBL (415 nm) were compared between C. albicans and human keratinocytes. The potential development of aBL resistance by C. albicans was investigated via 10 serial passages of C. albicans on aBL exposure. For the animal study, a mouse model of thermal burn infected with the bioluminescent C. albicans strain was used. aBL was delivered to mouse burns approximately 12 h after fungal inoculation. Bioluminescence imaging was performed to monitor in real time the extent of infection in mice. The results obtained from the studies demonstrated that C. albicans was approximately 42-fold more susceptible to aBL than human keratinocytes. Serial passaging of C. albicans on aBL exposure implied a tendency of reduced aBL susceptibility of C. albicans with increasing numbers of passages; however, no statistically significant difference was observed in the post-aBL survival rate of C. albicans between the first and the last passage (P>0.05). A single exposure of 432 J/cm(2) aBL reduced the fungal burden in infected mouse burns by 1.75-log10 (P=0.015). Taken together, our findings suggest aBL is a potential therapeutic for C. albicans infections.

Diagnosis and treatment of acute extremity compartment syndrome

Acute compartment syndrome of the extremities is well known, but diagnosis can be challenging. Ineffective treatment can have devastating consequences, such as permanent dysaesthesia, ischaemic contractures, muscle dysfunction, loss of limb, and even loss of life. Despite many studies, there is no consensus about the way in which acute extremity compartment syndromes should be diagnosed. Many surgeons suggest continuous monitoring of intracompartmental pressure for all patients who have high-risk extremity injuries, whereas others suggest aggressive surgical intervention if acute compartment syndrome is even suspected. Although surgical fasciotomy might reduce intracompartmental pressure, this procedure also carries the risk of long-term complications. In this paper in The Lancet Series about emergency surgery we summarise the available data on acute extremity compartment syndrome of the upper and lower extremities in adults and children, discuss the underlying pathophysiology, and propose a clinical guideline based on the available data.

Admission From Nursing Home Residence Increases Acute Mortality After Hip Fractures

BACKGROUND

Little is known about the effect of preinjury residence on inpatient mortality following hip fracture. This study addressed whether (1) admission from a nursing home residence and (2) admission from another hospital were associated with higher inpatient mortality after a hip fracture.

METHODS

Using the National Hospital Discharge Survey database, we analyzed an estimated 2 124 388 hip fractures discharges, from 2001 to 2007. Multivariable logistic regression analysis was performed to identify whether admission from a nursing home and admission from another hospital were independent risk factors for inpatient mortality. Our primary null hypothesis is that there is no difference in inpatient mortality rates after hip fracture in patients admitted from a nursing home, compared to other forms of admission. The secondary null hypothesis is that there is no difference in inpatient mortality after hip fracture in patients whose source of admission was another hospital, compared to other sources of admission.

RESULTS

Almost 4% of the patients were admitted from a nursing home and 6% from another hospital. The mean age was 79 years and 71% were women. The majority of patients were treated with internal fixation. Admission from a nursing home residence (odds ratio [OR] of 2.1, confidence interval [CI] 1.9-2.3) and prior hospital stay (OR 3.4, CI 3.2-3.7) were associated with a higher risk of inpatient mortality after accounting for other comorbidities and type of treatment.

CONCLUSIONS

Patients transferred to an acute care hospital from a long-term care facility or another acute care hospital are at particularly high risk of inpatient death. This subset of patients should be considered separately from patients admitted from other sources.

LEVEL OF EVIDENCE

Prognostic level II.

Comparison of locked plate fixation and nonoperative management for displaced proximal humerus fractures in elderly patients

Use of locked plate fixation for proximal humerus fractures in elderly patients has increased markedly in recent years. We conducted a study to compare outcomes of operative (locked plate fixation) and nonoperative management of these fractures. From our database, we identified 207 displaced proximal humerus fractures that met all inclusion and exclusion criteria. For patients who accepted our invitation to return for evaluation, clinical outcome was assessed using several questionnaires: Constant; DASH (Disabilities of the Arm, Shoulder, and Hand); SMFA (Short Musculoskeletal Functional Assessment); and Patient Reported Outcomes Measurement Information System (PROMIS) Physical Function Computer Adaptive Test. Of the 207 patients, 61 were managed operatively and 146 nonoperatively. Operative patients had lower rates of malunion but higher rates of complications, which included screw perforation, loss of fixation, infection, and secondary surgical procedures. Forty-seven patients (a mix of operative and nonoperative) accepted our invitation to return for clinical evaluation at a mean follow-up of 3.3 years. The 2 groups' clinical outcomes were similar.

Current management of posterior wall fractures of the acetabulum

The general goals for treating an acetabular fracture are to restore congruity and stability of the hip joint. These goals are no different from those for the subset of fractures of the posterior wall. Nevertheless, posterior wall fractures present unique problems compared with other types of acetabular fractures. Successful treatment of these fractures depends on a multitude of factors. The physician must understand their distinctive radiologic features, in conjunction with patient factors, to determine the appropriate treatment. By knowing the important points of posterior surgical approaches to the hip, particularly the posterior wall, specific techniques can be used for fracture reduction and fixation in these often challenging fractures. In addition, it is important to develop a complete grasp of potential complications and their treatment. The evaluation and treatment protocols initially developed by Letournel and Judet continue to be important; however, the surgeon also should be aware of new information published and presented in the past decade.

Does fluoroscopy improve acetabular component placement in total hip arthroplasty?

BACKGROUND

The success of THA largely depends on correct placement of the individual components. Traditionally, these have been placed freehand using anatomic landmarks, but studies have shown poor accuracy with this method.

QUESTIONS/PURPOSES

Specifically, we asked (1) does using fluoroscopy lead to more accurate and greater likelihood of cup placement with the Lewinnek safe zone than does freehand cup placement; (2) is there a learning curve associated with the use of fluoroscopy for cup placement; (3) does the use of fluoroscopy increase operative time; and (4) is there a difference in leg length discrepancy between freehand and fluoroscopic techniques?

METHODS

This series consisted of 109 consecutive patients undergoing primary THA, conversion of a previous hip surgery to THA, and revision THA during a 24-month period. No patients were excluded from analysis during this time. The first 52 patients had cups placed freehand, and then the next 57 patients had acetabular components placed using fluoroscopy; the analysis began with the first patient treated using fluoroscopy, to include our initial experience with the technique. The abduction, version, and limb length discrepancy were measured on 6-week postoperative pelvic radiographs obtained with the patient in the supine position. Operative time, sex, age, BMI, diagnosis, operative side, and femoral head size were recorded as possible confounders.

RESULTS

Cups inserted freehand were placed in the ideal range of abduction (30°-45°) and anteversion (5°-25°) 44% of the time. With fluoroscopy, placement in the Lewinnek safe zone for both measures significantly increased to 65%. The odds of placing the cup in the Lewinnek safe zone for abduction and version were 2.3 times greater with the use of fluoroscopy (95% CI, 1.2-5.0; p = 0.03). Patients undergoing primary THAs (32 freehand, 35 C-arm) had cup placement in the safe zone for abduction and version 44% of the time freehand and 57% of the time with fluoroscopy, which failed to reach statistical significance. There was no difference in operative time, patient age, sex, operative side, diagnosis, limb length discrepancy, or femoral head size between the two groups.

CONCLUSIONS

The use of fluoroscopy to directly observe pelvic position and acetabular component placement increased the success of placement in the Lewinnek safe zone in this cohort of patients having complex and primary THAs. This is a simple, low-cost, and quick method for increasing successful acetabular component alignment. The study population included a large proportion of patients having complex THAs, and further validation of this technique in patients undergoing straightforward, primary THAs needs to be done to understand if similar gains in accuracy for component placement can be expected in that group.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Application of epoxy resin to a solid-foam pelvic model: creating a dry-erase pelvis

The value of preoperative planning and templating has been well-established in fracture surgery. We have found that using 3-dimensional (3-D) models in preoperative planning aids in the understanding of anatomy, fracture-reduction techniques, and fixation methods, particularly in pelvic and acetabular fractures. To facilitate the correction of errors and reuse for future cases, we coat pelvic models with dry-erase epoxy resin. Fracture lines and planned implants are drawn onto the models with dry-erase markers. The creation of 3-D planning tools is useful in understanding the anatomy of pelvic and acetabular fractures.

The effect of the Massachusetts healthcare reform on the uninsured rate of the orthopaedic trauma population

BACKGROUND

The 2006 Massachusetts Healthcare Reform (MHR) has resulted in health coverage for 98.1% of residents in Massachusetts. The purpose of this study was to evaluate the effect of MHR on the actual rate of uninsured individuals in the orthopaedic trauma population in the largest metropolitan area of Massachusetts. We also sought to measure the change in uncompensated care following the implementation of MHR.

METHODS

We performed a retrospective review of all patients treated by the orthopaedic trauma services at three of the four level-I trauma centers in Boston from 2003 to 2010. The primary study cohort consisted of all uninsured patients, while the remaining patients were considered to have insurance. The study population was divided into two groups to compare the uninsured rate before and after MHR. Patients from 2006 to 2007 were excluded from the analysis to allow for an enrollment period in subsidized health insurance.

RESULTS

A total of 16,338 patients with extremity and pelvic fractures and dislocations were treated from 2003 to 2010. There was a significant decrease in the uninsured rate from 23.8% to 14.4% following MHR (p < 0.001). The post-MHR risk of being uninsured is approximately 0.6 times the pre-MHR risk, with a 95% confidence interval of 0.56 to 0.65. There was also a reduction in the proportion of uncompensated care from 16.7% to 11.5% after MHR.

CONCLUSIONS

There was an estimated 40% reduction in risk of uninsured individuals in the orthopaedic trauma population in the metropolitan Boston area following MHR. Despite a significant improvement, these results reveal a rate of uninsured individuals fivefold greater than currently reported by the state of Massachusetts and the U.S. government.

Predictive factors of distal femoral fracture nonunion after lateral locked plating: a retrospective multicenter case-control study of 283 fractures

INTRODUCTION

Reported initial success rates after lateral locked plating (LLP) of distal femur fractures have led to more concerning outcomes with reported nonunion rates now ranging from 0 to 21%. Reported factors associated with nonunion include comorbidities such as obesity, age and diabetes. In this study, our goal was to identify patient comorbidities, injury and construct characteristics that are independent predictors of nonunion risk in LLP of distal femur fractures; and to develop a predictive algorithm of nonunion risk, irrespective of institutional criteria for clinical intervention variability.

PATIENTS AND METHODS

A retrospective review of 283 distal femoral fractures in 278 consecutive patients treated with LLP at three Level1 academic trauma centers. Nonunion was liberally defined as need for secondary procedure to manage poor healing based on unrestricted surgeon criteria. Patient demographics (age, gender), comorbidities (obesity, smoking, diabetes, chronic steroid use, dialysis), injury characteristics (AO type, periprosthetic fracture, open fracture, infection), and management factors (institution, reason for intervention, time to intervention, plate length, screw density, and plate material) were obtained for all participants. Multivariable analysis was performed using logistic regression to control for confounding in order to identify independent risk factors for nonunion.

RESULTS

28 of the 283 fractures were treated for nonunion, 13 were referred to us from other institutions. Obesity (BMI>30), open fracture, occurrence of infection, and use of stainless steel plate were significant independent risk factors (P<0.01). A predictive algorithm demonstrates that when none of these variables are present (titanium instead of stainless steel) the risk of nonunion requiring intervention is 4%, but increases to 96% with all factors present. When a stainless plate is used, obesity alone carries a risk of 44% while infection alone a risk of 66%. While Chi-square testing suggested no institutional differences in nonunion rates, the time to intervention for nonunion varied inversely with nonunion rates between institutions, indicating varying trends in management approach.

DISCUSSION

Obesity, open fracture, occurrence of infection, and the use of stainless steel are prognostic risk factors of nonunion in distal femoral fractures treated with LLP independent of differing trends in how surgeons intervene in the management of nonunion.

Lateral migration with telescoping of a trochanteric fixation nail in the treatment of an intertrochanteric hip fracture

BACKGROUND

The trochanteric fixation nail (TFN) can be used to treat stable and unstable fractures of intertrochanteric hip fractures. We study the common lateral migration that occurs with telescoping of intertrochanteric hip fractures treated with TFN and identify the predictors and relationships to clinical outcomes.

METHODS

Patient demographic information, fracture type (Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Orthopaedic Trauma Association (OTA) classification), radiographic data, and clinical data were collected. Lateral migration with telescoping was measured. Statistical analyses were performed to determine which variables predicted lateral migration with telescoping. Patient outcome scores were recorded using the Modified Harris Hip Score (MHHS), Hip Outcome Score-Activity of Daily Living (HOS-ADL), and Visual Analog Scale for pain.

RESULTS

Two hundred and twenty-three patients (67 males, 156 females) fitted the radiographic and follow-up (average 24.6 months) criteria. The average age was 77.2 years. The average lateral migration with telescoping was 4.8 mm. Twenty-one patients (9.4%) had excessive lateral migration with telescoping ( = 10 mm). The quality of calcar reduction (P = 0.01) and unstable fracture patterns (P = 0.006) were significant predictive factors of lateral migration with telescoping. The mean outcome scores (MHHS and HOS-ADL) were 80.1 points and 78.7 points, respectively. All subjects had no significant relationship to lateral migration with telescoping (P > 0.05). Of all the patients who developed lateral migration with telescoping, only one required removal of the blade for hip pain and all patients went on to uneventful union at an average time of 4.5 months.

CONCLUSIONS

Lateral migration with telescoping is a common mechanical complication of intertrochanteric hip fracture treated with the TFN procedure. It was predicted by the quality of calcar reduction and fracture type. However, this did not affect stable fixation and fracture healing, so rarely leads to clinical problems.

Antimicrobial blue light therapy for multidrug-resistant Acinetobacter baumannii infection in a mouse burn model: implications for prophylaxis and treatment of combat-related wound infections

In this study, we investigated the utility of antimicrobial blue light therapy for multidrug-resistant Acinetobacter baumannii infection in a mouse burn model. A bioluminescent clinical isolate of multidrug-resistant A. baumannii was obtained. The susceptibility of A. baumannii to blue light (415 nm)-inactivation was compared in vitro to that of human keratinocytes. Repeated cycles of sublethal inactivation of bacterial by blue light were performed to investigate the potential resistance development of A. baumannii to blue light. A mouse model of third degree burn infected with A. baumannii was developed. A single exposure of blue light was initiated 30 minutes after bacterial inoculation to inactivate A. baumannii in mouse burns. It was found that the multidrug-resistant A. baumannii strain was significantly more susceptible than keratinocytes to blue light inactivation. Transmission electron microscopy revealed blue light-induced ultrastructural damage in A. baumannii cells. Fluorescence spectroscopy suggested that endogenous porphyrins exist in A. baumannii cells. Blue light at an exposure of 55.8 J/cm(2) significantly reduced the bacterial burden in mouse burns. No resistance development to blue light inactivation was observed in A. baumannii after 10 cycles of sublethal inactivation of bacteria. No significant DNA damage was detected in mouse skin by means of a skin TUNEL assay after a blue light exposure of 195 J/cm(2).

Do psychiatric comorbidities influence inpatient death, adverse events, and discharge after lower extremity fractures?

BACKGROUND

Psychiatric comorbidity is known to contribute to illness (the state of feeling unwell/unable to rely on one's body) and increased use of healthcare resources, but the effect on inpatient outcomes in fracture care is relatively unexplored.

QUESTIONS/PURPOSES

Our primary null hypothesis is that a concomitant diagnosis of depression, anxiety, dementia, or schizophrenia is not associated with (1) discharge to another care facility rather than home after lower extremity fractures. Secondary study questions address the associations between psychiatric comorbidity and (2) longer inpatient stay and inpatient (3) adverse events; (4) blood transfusion; and (5) mortality after lower extremity fractures.

METHODS

Using the National Hospital Discharge Survey database, we analyzed a total estimated number of 10,669,449 patients with lower limb fractures from 1990 to 2007. Sixty-four percent were women, and the mean±SD age was 67±22 years. The prevalence in the study population was 3.2% for depression, 1.6% for anxiety, 0.6% for schizophrenia, and 2.9% for dementia.

RESULTS

A discharge diagnosis of psychiatric comorbidity was associated with a lower rate of discharge to home after accounting for an association with greater medical comorbidity (schizophrenia: odds ratio [OR], 5.6, 95% confidence interval [CI], 5.5-5.8; dementia: OR, 1.3, 95% CI, 1.2-1.3; depression: OR, 1.2, 95% CI, 1.2-1.3; anxiety: OR, 1.04, 95% CI, 1.02-1.06). Hospital stay was longer for patients with schizophrenia and dementia but shorter in patients with depression or anxiety compared with patients without any mental disorders. Schizophrenia was associated with more in-hospital adverse events and depression and anxiety with fewer events. A diagnosis of depression was associated with blood transfusion. Psychiatric comorbidity was not associated with a higher risk of in-hospital death.

CONCLUSIONS

Optimal inpatient management of patients with lower extremity fractures should account for the influence of psychiatric comorbidities, dementia and schizophrenia in particular.

Inflammatory cytokines induce a unique mineralizing phenotype in mesenchymal stem cells derived from human bone marrow

Bone marrow contains mesenchymal stem cells (MSCs) that can differentiate along multiple mesenchymal lineages. In this capacity they are thought to be important in the intrinsic turnover and repair of connective tissues while also serving as a basis for tissue engineering and regenerative medicine. However, little is known of the biological responses of human MSCs to inflammatory conditions. When cultured with IL-1β, marrow-derived MSCs from 8 of 10 human subjects deposited copious hydroxyapatite, in which authenticity was confirmed by Fourier transform infrared spectroscopy. Transmission electron microscopy revealed the production of fine needles of hydroxyapatite in conjunction with matrix vesicles. Alkaline phosphatase activity did not increase in response to inflammatory mediators, but PPi production fell, reflecting lower ectonucleotide pyrophosphatase activity in cells and matrix vesicles. Because PPi is the major physiological inhibitor of mineralization, its decline generated permissive conditions for hydroxyapatite formation. This is in contrast to MSCs treated with dexamethasone, where PPi levels did not fall and mineralization was fuelled by a large and rapid increase in alkaline phosphatase activity. Bone sialoprotein was the only osteoblast marker strongly induced by IL-1β; thus these cells do not become osteoblasts despite depositing abundant mineral. RT-PCR did not detect transcripts indicative of alternative mesenchymal lineages, including chondrocytes, myoblasts, adipocytes, ligament, tendon, or vascular smooth muscle cells. IL-1β phosphorylated multiple MAPKs and activated nuclear factor-κB (NF-κB). Certain inhibitors of MAPK and PI3K, but not NF-κB, prevented mineralization. The findings are of importance to soft tissue mineralization, tissue engineering, and regenerative medicine.

Diagnosis of union of distal tibia fractures: accuracy and interobserver reliability

Decisions about return to activity and additional surgery are often made on the basis of radiographs obtained 3 months after injury. If radiographs 3 months after injury cannot reliably and accurately diagnose union, then patients may be needlessly disabled and might receive unnecessary treatments including surgery. We evaluated the accuracy and the reliability of the diagnosis of union or eventual union on radiographs obtained 3 months after open reduction and internal fixation of a fracture of the distal tibia by having 69 trauma surgeons evaluate radiographs of 33 consecutively treated patients in an online survey. Observers were also asked to judge specific criteria that are commonly used to diagnose fracture union. There was moderate interobserver reliability for the diagnosis of union or diagnosis of "eventual union". The interobserver agreement for the various specific radiographic signs of union varied between fair to moderate. The sensitivity of radiographs for diagnosis of "union or eventual union" of distal tibia fractures was 47%, the specificity was 73% and the accuracy was 68%. The prevalence adjusted positive predictive value was 25% and the negative predictive value was 88%. Diagnosis of union based on radiographs 3 months after injury is only moderately reliable and accurate but has a high negative predictive value. Decisions about activity level and additional treatment 3 months after injury should not be based on radiographs alone.

Factors associated with the decision for operative versus non-operative treatment of displaced proximal humerus fractures in the elderly

BACKGROUND

In the management of displaced proximal humerus fractures in the elderly, wide variation has been documented. However, no prior study has investigated the factors that currently lead surgeons to treat patients with surgical fixation, arthroplasty or non-operative management. The purpose of this study was to identify the factors associated with treatment selection in the management of displaced proximal humerus fractures in individuals over the age of 60 years. To this end, we conducted a retrospective review of all such injuries that presented to our two level-I trauma centres between 2006 and 2009.

PATIENTS AND METHODS

From our prospectively collected trauma database, we identified 229 displaced proximal humerus fractures that met all inclusion and exclusion criteria. Data were collected on patient-, fracture- and surgeon-related characteristics that were plausibly related to the decision for treatment. The choice of management was recorded, and logistic regression was used to identify factors associated with the decision for treatment.

RESULTS

In the multivariate analysis, the predictors of operative intervention as opposed to non-operative treatment were younger patient age (p = 0.038), associated orthopaedic injuries requiring surgery (p = 0.012), higher Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification (p = 0.012), translation-type displacement (p = 0.0012) and associated glenohumeral dislocation (p = 0.0006). In addition, shoulder and upper extremity specialists were found to choose operative intervention significantly more frequently than orthopaedic trauma specialists (49.1% vs. 26.1%, adjusted relative risk (RR) 1.96, p = 0.012). Factors associated with the decision for arthroplasty as opposed to fixation were higher Charlson score (p = 0.045), higher Neer classification (p = 0.012), and higher AO classification (p = 0.0097).

CONCLUSIONS

In this study of displaced proximal humerus fractures in the elderly, the decision for surgery was influenced by the patient's age, the presence of associated orthopaedic injuries, the severity of the fracture and the presence of an associated glenohumeral dislocation. In addition, treatment by a shoulder or upper extremity specialist (as opposed to an orthopaedic trauma specialist) was associated with a higher likelihood of operative intervention. Further investigation into the resultant clinical outcomes is required to determine whether the use of these characteristics to select operative candidates is appropriate and beneficial for patients.

Helicopter emergency medical services crew administration of antibiotics for open fractures

This study had 3 major aims: (1) to ascertain the degree to which helicopter emergency medical services (HEMS) administration of antibiotics (Abx) can streamline the time to Abx in open fracture patients, (2) to determine whether any clinical outcome improvements were associated with HEMS Abx therapy, and (3) to calculate the cost-effectiveness of prehospital HEMS Abx. The design of the study was a prospective, nonrandomized, nonintervention, natural study of timing and clinical outcomes for patients with suspected open extremity fracture. There were 138 scene trauma cases transported by 8 participating HEMS programs from July 2009 to June 2010. The participating HEMS programs were both urban and rural. The diagnosis of an open fracture by the HEMS crews had an accuracy rate of 97.8% (95% confidence interval, 90.8%-98.4%). The time from the incident to Abx was 30 minutes shorter (P = .0001) when Abx were administered by HEMS crews. There was no statistical significance (P = 1.0) regarding the endpoint of infection or nonunion development in HEMS- versus hospital-administered Abx. In conclusion, the administration of Abx by HEMS crews to patients diagnosed with open extremity fractures is feasible, it may decrease the time to Abx by 30 minutes, and the effect magnitude (40.3% relative risk reduction) was promising.

Blue light eliminates community-acquired methicillin-resistant Staphylococcus aureus in infected mouse skin abrasions

BACKGROUND AND OBJECTIVE

Bacterial skin and soft tissue infections (SSTI) affect millions of individuals annually in the United States. Treatment of SSTI has been significantly complicated by the increasing emergence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) strains. The objective of this study was to demonstrate the efficacy of blue light (415 ± 10 nm) therapy for eliminating CA-MRSA infections in skin abrasions of mice.

METHODS

The susceptibilities of a CA-MRSA strain (USA300LAC) and human keratinocytes (HaCaT) to blue light inactivation were compared by in vitro culture studies. A mouse model of skin abrasion infection was developed using bioluminescent USA300LAC::lux. Blue light was delivered to the infected mouse skin abrasions at 30 min (acute) and 24 h (established) after the bacterial inoculation. Bioluminescence imaging was used to monitor in real time the extent of infection in mice.

RESULTS

USA300LAC was much more susceptible to blue light inactivation than HaCaT cells (p=0.038). Approximately 4.75-log10 bacterial inactivation was achieved after 170 J/cm(2) blue light had been delivered, but only 0.29 log10 loss of viability in HaCaT cells was observed. Transmission electron microscopy imaging of USA300LAC cells exposed to blue light exhibited disruption of the cytoplasmic content, disruption of cell walls, and cell debris. In vivo studies showed that blue light rapidly reduced the bacterial burden in both acute and established CA-MRSA infections. More than 2-log10 reduction of bacterial luminescence in the mouse skin abrasions was achieved when 41.4 (day 0) and 108 J/cm(2) (day 1) blue light had been delivered. Bacterial regrowth was observed in the mouse wounds at 24 h after the blue light therapy.

CONCLUSIONS

There exists a therapeutic window of blue light for bacterial infections where bacteria are selectively inactivated by blue light while host tissue cells are preserved. Blue light therapy has the potential to rapidly reduce the bacterial load in SSTI.

What are the patterns of injury and displacement seen in lateral compression pelvic fractures?

BACKGROUND

Lateral compression (LC)-type pelvic fractures encompass a wide spectrum of injuries. Current classification systems are poorly suited to help guide treatment and do not adequately describe the wide range of injuries seen in clinical practice.

QUESTIONS/PURPOSES

We therefore (1) defined the spectrum of injuries that compose LC fractures with respect to both anterior and posterior ring injuries, with particular focus on the morphology of sacral fractures, and (2) identified fracture patterns associated with displacement at presentation.

METHODS

We retrospectively reviewed 318 LC pelvic fractures. Displacement of the anterior pelvic ring was identified and measured on plain radiographs and posterior displacement was identified by CT.

RESULTS

All 318 patients had an anterior injury and all but 13 (4%) had a posterior injury; 263 of the 318 fractures (87%) included a sacral fracture, with 162 of 318 (51%) having an anterior incomplete sacral fracture, 53 (17%) a complete simple fracture, and 48 (15%) a complete comminuted fracture. Forty-two of 318 (13%) had a crescent fracture. One hundred six of 318 (33%) were displaced at presentation. There was a higher incidence of initial displacement observed in fractures including bilateral rami fractures, a comminuted sacral fracture, or a crescent fracture.

CONCLUSIONS

LC pelvic fractures represent a heterogeneous group of injuries with a wide range of associated fracture patterns. In particular, there is a wide range of fracture types represented by injuries classified as LC1 (involving any sacral fracture). Fractures with more complex sacral fractures, crescent fractures, or bilateral pubic rami fractures tend to have higher degrees of initial displacement.

LEVEL OF EVIDENCE

Level IV, diagnostic study. See Instructions for Authors for a complete description of levels of evidence.

Ultraviolet C irradiation: an alternative antimicrobial approach to localized infections?

This review discusses the potential of ultraviolet C (UVC) irradiation as an alternative approach to current methods used to treat localized infections. It has been reported that multidrug-resistant microorganisms are equally sensitive to UVC irradiation as their wild-type counterparts. With appropriate doses, UVC may selectively inactivate microorganisms while preserving viability of mammalian cells and, moreover, is reported to promote wound healing. UVC is also found in animal studies to be less damaging to tissue than UVB. Even though UVC may produce DNA damage in mammalian cells, it can be rapidly repaired by DNA repair enzymes. If UVC irradiation is repeated excessively, resistance of microorganisms to UVC inactivation may develop. In summary, UVC should be investigated as an alternative approach to current methods used to treat localized infections, especially those caused by multidrug-resistant microorganisms. UVC should be used in a manner such that the side effects would be minimized and resistance of microorganisms to UVC would be avoided.

Fracture pattern and fixation type related to loss of reduction in bicondylar tibial plateau fractures

INTRODUCTION

Bicondylar tibial plateau fractures can be treated with locked plating applied from the lateral side with or without additional application of a medial plate (dual plating). Recent studies demonstrate that these injuries can be sub-grouped based upon their morphology by computed tomography (CT). The purpose of this study is to evaluate the relationship between fracture pattern, method of fixation and loss of reduction in bicondylar tibial plateau fractures.

PATIENTS AND METHODS

Preoperative CT scans and postoperative plain films were evaluated on a consecutive series of bicondylar tibial plateau fractures. Fracture patterns were classified by CT. Angular alignment was measured immediately postoperatively and again at clinical and radiographic union to assess loss of reduction.

RESULTS

A total of 140 patients were studied. Sixty-six (47%) had a single large medial fragment with the articular surface intact, 19 (14%) had a medial articular fracture line with a mainly sagittal component and 55 (39%) had a coronal fracture through the medial articular surface. A total of 129 patients had been treated with lateral locked plating alone whilst 11 patients (all with a coronal fracture of the medial condyle) underwent dual plating. There was little loss of reduction (median subsidence 0.5°) when lateral locked plating was employed alone in patients with a single medial fracture fragment or with a sagittal medial fracture line. When lateral locked plating was used in the presence of a medial coronal fracture line, there was a significantly higher rate of subsidence (median 2.0°) compared to those with no medial fracture line (p=0.002). Patients with coronal fracture lines treated with dual plating had significantly less loss of reduction that those treated with lateral locked plating (p=0.01).

CONCLUSIONS

Most patients with bicondylar tibial plateau fractures do well when treated with lateral locked plating. However, those with a medial coronal fracture line tend to have a higher rate of subsidence and loss of reduction when lateral locked plating is employed alone. These fractures may be better treated with dual plating if the soft tissues allow.

LEVEL OF EVIDENCE

Level III (retrospective comparative study).

The role of stem cells in fracture healing and nonunion

Nonunion and large bone defects present a therapeutic challenge to the surgeon and are often associated with significant morbidity. These defects are expensive to both the health care system and society. However, several surgical procedures have been developed to maximise patient satisfaction and minimise health-care-associated and socioeconomic costs. Integrating recent evidence into the diamond concept leads to one simple conclusion that not only provides us with answers to the "open questions" but also simplifies our entire understanding of bone healing. It has been shown that a combination of neo-osteogenesis and neovascularisation will restore tissue deficits, and that the optimal approach includes a biomaterial scaffold, cell biology techniques, a growth factor and optimisation of the mechanical environment. Further prospective, controlled, randomised clinical studies will determine the effectiveness and economic benefits of treatment with mesenchymal stem cells, not in comparison to other conventional surgical approaches but in direct conjunction with them.

Nonoperative versus prophylactic treatment of bisphosphonate-associated femoral stress fractures

BACKGROUND

Several studies have identified a specific fracture in the proximal diaphysis of the femur in patients treated with bisphosphonates. The fractures typically are sustained after a low-energy mechanism with the presence of an existing characteristic stress fracture. However, it is unclear whether these patients are best treated nonoperatively or operatively.

QUESTIONS/PURPOSES

What is the likelihood of nonoperatively treated bisphosphonate-associated femoral stress fractures progressing to completion and during what time period? If prophylactic fixation is performed, do patients have a shorter hospital length-of-stay compared with patients having surgical fixation after fracture completion?

PATIENTS AND METHODS

We retrospectively searched for patients older than 50 years receiving bisphosphonate therapy, with either incomplete, nondisplaced stress fractures or completed, displaced fractures in the proximal diaphysis of the femur between July 2002 and April 2009. After applying exclusion criteria, we identified 34 patients with a total of 40 bisphosphonate-associated fractures. The average duration of bisphosphonate use was 77 months. Twenty-eight of 40 (70%) fractures were completed, displaced fractures. Six of the 12 nondisplaced stress fractures initially were treated nonoperatively. The remaining six stress fractures were treated with prophylactic cephalomedullary nail fixation. The minimum followup was 12 months (mean, 36.5 months; range, 12-72 months).

RESULTS

Five of the six stress fractures treated nonoperatively progressed to fracture completion and displacement at an average of 10 months (range, 3-18 months). The average hospital stay was 3.7 days for patients treated prophylactically and 6.0 days for patients treated after fracture completion.

CONCLUSIONS

Our data suggest nonoperative treatment of bisphosphonate-related femoral stress fractures is not a reliable way to treat these fractures as the majority progress to fracture completion. Prophylactic fixation of femoral stress fractures also reduces total hospital admission time.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Osteochondral autograft transplantation for acute osteochondral fractures associated with an ankle fracture

BACKGROUND

Osteochondral fractures of the talar dome (OCFT) are frequently associated with ankle fractures. Controversy exists regarding the treatment of acute Grade III and IV OCFT. Osteochondral autograft transplantation (OAT) is a possible operative solution.

MATERIALS AND METHODS

We performed OAT in 16 patients with acute Grade III or IV OCFT. There were ten males and six females with the average age of 33.9 (range, 18 to 49) years. The average period of followup was 36.3 (range, 21 to 48) months. OCFT was identified, and clinically determined to be Grade III or IV using radiographs and intraoperative assessment. Seven patients were Grade III, nine patients were Grade IV OCFT. The OAT consisted of two sequential procedures: 1) harvesting of osteochondral autograft cylinder from the nonweightbearing surface of the ipsilateral knee, and 2) implanting the donor graft into the talar defect with press-fit technique. Single cylinder transplantation or a mosaicplasty was used. The outcome was determined by the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, the simplified symptomatology evaluation, plain radiography and MRI.

RESULTS

The mean size of the osteochonral fracture defects was 84.1 (range, 50 to 125) mm(2), and the mean depth was 2.5 (range, 1 to 5) mm. The mean AOFAS score was 95.4 (range, 86 to 100) points postoperatively. At the latest followup, there was no radiographic evidence of post-traumatic arthritis. Based on the MRI of all patients, 93.7% of the osteochondral grafts showed bony integration and articular congruity of the talar dome.

CONCLUSION

OAT was shown to be an effective treatment with excellent clinical outcome and imaging evidence of graft integration.

Autologous bone grafting on steroids: preliminary clinical results. A novel treatment for nonunions and segmental bone defects

Clinical management of delayed healing or nonunion of long bone fractures and segmental bone defects poses a substantial orthopaedic challenge. Surgical advances and bone tissue engineering are providing new avenues to stimulate bone growth in cases of bone loss and nonunion. The reamer-irrigator-aspirator (RIA) device allows surgeons to aspirate the medullary contents of long bones and use the progenitor-rich "flow-through" fraction in autologous bone grafting. Dexamethasone (DEX) is a synthetic steroid that has been shown to induce osteoblastic differentiation. A series of 13 patients treated with RIA bone grafting enhanced with DEX for nonunion or segmental defect was examined retrospectively to assess the quality of bony union and clinical outcomes. Despite the initial poor prognoses, promising results were achieved using this technique; and given the complexity of these cases the observed success is of great value and warrants controlled study into both standardisation of the procedure and concentration of the grafting material.

The surgical treatment of acetabular fractures

The goals of treating an acetabular fracture are to restore the congruity and stability of the hip joint. Some fracture types may not require surgery for a satisfactory outcome, but a displaced fracture in the weight-bearing area of the acetabulum generally should be treated with open reduction and internal fixation. The surgery is complex and demanding, and the fracture reduction must be anatomic to obtain the best result. There is no doubt, however, that an experienced surgeon can achieve an excellent result. Usually a poor result is related to residual fracture displacement or a perioperative complication. The evaluation and treatment protocols initially developed by Letournel and Judet continue to be important; in addition, the surgeon should be aware of the progress made during the past decade.

Osteogenic potential of reamer irrigator aspirator (RIA) aspirate collected from patients undergoing hip arthroplasty

Intramedullary nailing preceded by canal reaming is the current standard of treatment for long-bone fractures requiring stabilization. However, conventional reaming methods can elevate intramedullary temperature and pressure, potentially resulting in necrotic bone, systemic embolism, and pulmonary complications. To address this problem, a reamer irrigator aspirator (RIA) has been developed that combines irrigation and suction for reduced-pressure reaming with temperature modulation. Osseous particles aspirated by the RIA can be recovered by filtration for use as an autograft, but the flow-through is typically discarded. The purpose of this study was to assess whether this discarded filtrate has osteogenic properties that could be used to enhance the total repair potential of aspirate. RIA aspirate was collected from five patients (ages 71-78) undergoing hip hemiarthroplasty. Osseous particles were removed using an open-pore filter, and the resulting filtrate (230 +/- 200 mL) was processed by Ficoll-gradient centrifugation to isolate mononuclear cells (6.2 +/- 5.2 x 10(6) cells/mL). The aqueous supernatant contained FGF-2, IGF-I, and latent TGF-beta1, but BMP-2 was below the limit of detection. The cell fraction included culture plastic-adherent, fibroblastic cells that displayed a surface marker profile indicative of mesenchymal stem cells and that could be induced along the osteogenic, adipogenic, and chondrogenic lineages in vitro. When compared to outgrowth cells from the culture of osseous particles, filtrate cells were more sensitive to seeding density during osteogenic culture but had similar capacity for chondrogenesis. These results suggest using RIA aspirate to develop improved, clinically expeditious, cost-effective technologies for accelerating the healing of bone and other musculoskeletal tissues.

Bone tissue engineering and repair by gene therapy

Many clinical conditions require the stimulation of bone growth. The use of recombinant bone morphogenetic proteins does not provide a satisfying solution to these conditions due to delivery problems and high cost. Gene therapy has emerged as a very promising approach for bone repair that overcomes limitations of protein-based therapy. Several preclinical studies have shown that gene transfer technology has the ability to deliver osteogenic molecules to precise anatomical locations at therapeutic levels for sustained periods of time. Both in-vivo and ex-vivo transduction of cells can induce bone formation at ectopic and orthotopic sites. Genetic engineering of adult stem cells from various sources with osteogenic genes has led to enhanced fracture repair, spinal fusion and rapid healing of bone defects in animal models. This review describes current viral and non-viral gene therapy strategies for bone tissue engineering and repair including recent work from the author's laboratory. In addition, the article discusses the potential of gene-enhanced tissue engineering to enter widespread clinical use.

Healing of segmental bone defects by direct percutaneous gene delivery: effect of vector dose

Previous studies have demonstrated the ability of direct adenoviral BMP-2 (Ad.BMP-2) gene delivery to enhance bone repair. Nevertheless, in studies using a rat segmental defect model, it has not proved possible to achieve reliably full osseous union in all animals. To address this issue, we evaluated the effect of vector dose on healing. Critical-size defects were created in the right femora of 27 Sprague-Dawley rats. The defects received a single, intralesional, percutaneous injection of 2.7 x 10(7) (low dose), 2.7 x 10(8) (medium dose), or 2.7 x 10(9) (high dose) plaque-forming units of Ad.BMP-2. After 8 weeks, femora were evaluated by X-ray, dual-energy X-ray absorptiometry, microcomputed tomography (microCT), and histology. The high dose of vector bridged 100%, the medium dose 11%, and the low dose 25% of the defects, as evaluated by X-ray and microCT imaging. Bone mineral content and bone volume of the defects receiving the high dose of vector were significantly higher than those of both groups receiving lower doses. Histologically, defects treated with the high dose were filled by trabecular bone and small amounts of cartilage, whereas large areas of fibrous tissue and cartilage remained in the defects receiving lower doses. However, the newly formed bone lacked the structural organization of native bone, suggesting that further maturation is necessary.

Delayed administration of adenoviral BMP-2 vector improves the formation of bone in osseous defects

The direct, local, administration of adenovirus carrying human BMP-2 cDNA (Ad.BMP-2) heals critical-sized femoral bone defects in rabbit and rat models. However, the outcome is suboptimal and the technology needs to provide a more reliable and uniform outcome. To this end, we investigated whether the timing of Ad.BMP-2 administration influenced the formation of mineralized tissue within the defect. Critical-sized defects were created in the femora of 28 Sprague-Dawley rats. Animals were injected intralesionally with a single, percutaneous injection of Ad.BMP-2 (4 x 10(8) plaque-forming units) either intraoperatively (day 0) or 24 h (day 1), 5 days or 10 days after surgery. The femora were evaluated 8 weeks after surgery by X-ray, microcomputed tomography, dual-energy X-ray absorptiometry and biomechanical testing. The incidence of radiological union was markedly increased when administration of Ad.BMP-2 was delayed until days 5 and 10, at which point 86% of the defects healed. These time points also provided greater bone mineral content within the defect site and improved the average mechanical strength of the healed bone. Thus, delaying the injection of Ad.BMP-2 until 5 or 10 days after surgery enables a greater percentage of critical-sized, segmental defects to achieve radiological union, producing a repair tissue with enhanced mineralization and greater mechanical strength.

Depression in orthopaedic trauma patients. Prevalence and severity

BACKGROUND

There is a known connection between physical injury and disability and emotional distress. Several investigators have shown a relationship between trauma, depression, and poor outcomes. The literature on trauma and depression is limited with regard to clarifying the relationship between the degree of injury and depression and the relationship between physical function of patients with less severe injuries and depression.

METHODS

One hundred and sixty-one patients who presented to our orthopaedic trauma services were enrolled in the study and interviewed. We obtained information about patient demographics and administered several self-reported outcome measures: the Beck Depression Inventory (BDI), the Short Musculoskeletal Function Assessment (SMFA), and the Physical Function-10 (PF-10) subset of the Short Form-36 (SF-36). We documented the nature and severity of the injury or injuries and calculated correlations between the outcome measures and the BDI. Injury-specific factors such as the AO Fracture Classification, the Abbreviated Injury Scale (AIS), the Injury Severity Score (ISS), and the Gustilo and Anderson grade of open fractures were also examined.

RESULTS

Fifty-five percent of the patients had minimal depression, as measured with the BDI; 28% had moderate depression; 13% had moderate-to-severe depression; and 3.7% had severe depression. When the somatic elements of the BDI were removed, the prevalence of moderate, moderate-to-severe, or severe depression was 26%. The SMFA scores had a strong negative correlation with the BDI (-0.75; p < 0.001). Of the injury-specific factors, only open factures were found to have an impact on the presence of depression, with an odds ratio of 4.58 (95% confidence ratio, 1.57 to 12.35).

CONCLUSIONS

The prevalence of clinically relevant depression approached 45% in a diverse cohort of orthopaedic trauma patients. Global disability is strongly correlated with depression. The presence of an open fracture may also increase the risk of depression.

LEVEL OF EVIDENCE

Prognostic Level II.

Low complication rate of LISS for femur fractures adjacent to stable hip or knee arthroplasty

Fractures of the femur after a knee or hip arthroplasty historically have been plagued with high complication rates. The Less Invasive Stabilization System (LISS) has theoretical advantages of improved biomechanics and limited insult to the bone's vascular supply. We theorized that the LISS would have a lower complication rate than historical controls for these fractures. Patients who were treated with a LISS at two Level I trauma centers from July 2001 to July 2003 were prospectively followed up. The inclusion criteria were an acute fracture of the femur treated with a LISS in a patient with a stable ipsilateral total knee prosthesis and/or hip pros- thesis. There were 24 patients in the study group. The injury mechanism was a low-energy fall for all patients. All patients were females with an average age of 79.5 years (range. 64-93 years). Ten patients had ipsilateral hip arthroplasties, nine patients had ipsilateral total knee arthroplasties, and five patients had knee and hip arthroplasties. Followup was at an average of 48 weeks (range, 17-101 weeks). Eighteen of the 19 fractures in the surviving patients with followup healed uneventfully for a complication rate of 5.2%. One fracture was complicated by hardware pullout and was revised to a longer LISS that healed uneventfully. We think our data show that our patients had a low complication rate compared with that of historical controls, and we suggest that the LISS may be an appropriate treatment alternative for femur fractures associated with stable hip or knee prostheses.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

The value of the dedicated orthopaedic trauma operating room

BACKGROUND

Trauma centers and orthopaedic surgeons have traditionally been faced with limited operating room (OR) availability for fracture surgery. Orthopaedic trauma cases are often waitlisted and done late at night. We investigated the feasibility of having an unbooked orthopaedic trauma OR to reduce nighttime cases and improve OR flow.

METHODS

A retrospective analysis was performed for two 1 year time periods before and after the introduction of an unbooked trauma OR. The unbooked trauma OR is kept open for urgent and semi-urgent cases from 7:45 am to 5 pm 6 days per week, and is under the control of Orthopaedics; no elective cases are scheduled in the unbooked trauma room. We collected OR time data on two common surgical cases (dynamic hip screw and closed femoral nailing) done before and after introduction of the unbooked orthopaedic trauma OR. We also reviewed data on waitlist cases, surgical time, anesthetic times, OR utilization, and surgical complications before and after the introduction of the unbooked trauma room.

RESULTS

The availability of the unbooked trauma OR significantly improved operating suite flow. The proportion of hip fractures done after 5 pm was reduced by 72% (p<0.01). The number of all orthopaedic waitlist cases started after 5 pm was reduced by 6% (p<0.021). The distinct shift toward performing add-on cases during daytime hours resulted in a 6% reduction in OR over-utilization. Closed femoral nailing done at night required significantly more OR time (261 minutes versus 219 minutes, p<0.04). Hip fracture surgeries and femoral nailings done at night were noted to have a higher incidence of surgical complications (p<0.04 and p<0.036).

CONCLUSION

The availability of an unbooked orthopaedic trauma room resulted in a measurable shift from performing "add-on" cases to daytime surgery and may reduce complications. We recommend that hospitals and orthopaedic trauma services commit resources toward having an open OR reserved for orthopaedic trauma.

Review of the pathophysiology and acute management of haemorrhage in pelvic fracture

Mortality following pelvic fractures has declined dramatically as better methods of controlling haemorrhage, such as angioembolisation to control arterial bleeding, have been introduced. But about 10% of patients still die, despite these advances. To save these patients, the key questions in managing pelvic fractures are: which patients are at highest risk for a life-threatening bleed, in these patients, what is the exact anatomical source of the bleeding and what is the best way to stop it? There is wide consensus that bleeding is most likely to occur with unstable fractures. However, it remains difficult to predict which fractures will actually cause excessive bleeding. Current treatment protocols rely on angiographic embolisation and external fixation, either alone or in combination. Direct pelvic packing is gaining in popularity, but, ultimately, the ideal treatment method remains unclear. The purpose of this review is to examine our current understanding of the pathophysiology and management of bleeding pelvic fractures.