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Background: Orthopedic procedures often require removing bone or pathological tissue, with traditional methods involving instruments like curettes and rongeurs. However, these methods can be time-consuming and lead to increased blood loss. To mitigate these side effects, vacuum-assisted tools have been developed to aid in tissue removal. These devices enable surgeons to suction tissue without discarding it, potentially improving outcomes in conditions such as osteomyelitis or tumor removal while enabling collection of the material for downstream applications. Despite limited research, vacuum-assisted devices show promise beyond bone marrow harvesting. This study assesses infection and clearance rates, estimated blood loss, and total procedure time associated with the use of vacuum-assisted tissue removal, with a goal to understand if these devices can be used for tissue removal across a variety of pathologic conditions., Methods: A retrospective cohort study was conducted on patients undergoing orthopedic procedures with the Avitus® Bone Harvester repurposed from its original design from December 1, 2021, to July 1, 2023. Procedures were categorized into oncology, and debridement for infection cases. Infection cases were further categorized into those secondary to trauma and those involving primary infections (osteomyelitis and periprosthetic joint infection). Clinical variables, including demographics, intraoperative details, complications, and follow-up, were reviewed. Statistical analysis included descriptive statistics computed with R Studio., Results: The study included 44 patients, with debridement for infection cases being the most common (primary infection: 45.5%; infection secondary to trauma: 18.1%), followed by oncology cases (36.4%). In all oncology cases, a definitive diagnosis was established using the device, and no post-operative infections were reported. The infection clearance rate was 85.0% for primary infection cases and 50.0% for cases of infection following trauma. Across the entire cohort, the average blood loss was 314.52 mL (sd: 486.74), and the average total procedure time was 160.93 min (sd: 91.07). The overall reoperation rate was 47.7%, with an unplanned reoperation rate of 11.4%., Conclusion: The vacuum-assisted bone harvester was effectively utilized in a wide range of debridement and curettage procedures across diverse orthopedic surgeries. In oncology cases, the device enabled effective tissue removal with comparable recurrence rates, demonstrating its potential to minimize contamination while preserving tissue for accurate diagnoses. Additionally, a high rate of osteomyelitis eradication was observed in debridement for primary infection cases (85%). Despite the relatively high reoperation rate of 47.7%, it is crucial to interpret this figure within the context of the varied reasons for reoperation. Many of these reoperations were planned as part of a staged approach to treatment or were unrelated to the device's performance. It is crucial to acknowledge that isolating the device's contribution to these results can be difficult. The utilization of the device should be guided by considerations of cost-effectiveness and patient-specific risk factors., (© 2024. The Author(s).)

Objectives: Racial disparities in healthcare outcomes exist, including in orthopaedic trauma care. The aim of this study was to determine the impact of race, social deprivation, and payor status on 90-day emergency department (ED) revisits among orthopaedic trauma surgery patients at a Level 1 trauma academic medical center., Design: Retrospective chart review analysis., Setting: Level 1 trauma academic center in Durham, NC., Patient Selection Criteria: Adult patients undergoing orthopaedic trauma surgery between 2017 and 2021., Outcome Measures and Comparisons: The primary outcome of this retrospective cohort study was 90-day return to the ED. Logistic regression analysis was performed for variables of interest [race, social deprivation (measured by the Area Deprivation Index), and payor status] separately and combined, with each model adjusting for distance to the hospital. Results were interpreted as odds ratios (ORs) of 90-day ED revisits comparing levels of the respective variables. Statistical significance was assessed at α = 0.05., Results: A total of 3120 adult patients who underwent orthopaedic trauma surgery between 2017 and 2021 were included in the analysis. Black race (OR = 1.47; 95% confidence interval [CI]: 1.17-1.84, P < 0.001) and Medicaid coverage (OR = 1.63, 95% CI: 1.20-2.21, P = 0.002) were significantly associated with higher odds of return to ED compared with non-Black or non-Medicaid-covered patients. While ethnic minority (Hispanic/Latino or non-White) was statistically significant while adjusting only for distance to the hospital (OR = 1.23, 95% CI: 1.00-1.50, P = 0.047), it was no longer significant after adjusting for the other sociodemographic variables (OR = 1.13, 95% CI: 0.91-1.39, P = 0.27). The weighted Area Deprivation Index was not associated with a difference in odds of return to ED in any adjusted models., Conclusions: The results highlight the presence of racial and socioeconomic disparities in ED utilization, with Black race and Medicaid coverage significantly associated with higher odds of return to the ED. Future research should delve deeper into comprehending the root causes contributing to these racial and socioeconomic utilization disparities and evaluate the effectiveness of targeted interventions to reduce them., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: sub-Saharan Africa experiences a significant musculoskeletal trauma burden. Among patients who receive surgical treatment, there have been no reports as to how often surgical care is determined to be "adequate" or, if "inadequate", then what hospital and orthopaedic specialty-specific systems limitations might be prohibitive., Methods: data from patients presenting to the orthopaedic trauma service at a tertiary care center in sub-Saharan Africa were prospectively collected over a 6-week period and then retrospectively reviewed to determine whether the surgical treatment was "adequate" (or otherwise, "inadequate") according to the principle of restoring length, alignment, and rotation. Exclusion criteria included insufficient clinical information; isolated spinal injury; infection; cases involving only removal of hardware; soft-tissue procedures; tumor cases; and medical (non-surgical) conditions., Results: 112 cases were included for analysis. Surgery was indicated in 106 of 112 cases (94.6%), and of those, surgery was performed in 62 cases (58.4%). Among patients who underwent surgery with available post-operative imaging (n=56), surgical treatment was "inadequate" in 24 cases (42.9%). The most common reasons treatment was deemed "inadequate" included unavailability of appropriate implants (n=16), unavailability of intraoperative fluoroscopy (n=10) and incomplete intraoperative evaluation of injury (n=5)., Conclusion: several systems limitations prevent the delivery of adequate surgical treatment in patients with acute orthopaedic traumatic injuries, including lack of intraoperative fluoroscopy and lack of implant availability. This study will serve as a useful baseline for ongoing efforts seeking to improve orthopaedic specialty resource availability and facilitate more effective fracture care in this region., Competing Interests: The authors declare no competing interests., (Copyright: Papa Kwadwo Morgan-Asiedu et al.)

Intraoperative fractures of the acetabulum are a rare but serious complication during total hip arthroplasty. Acute fractures generally require attention with plating, whereas chronic acetabular fractures may be approached with distraction, a Burch-Schneider cage, or a custom implant. It is imperative for arthroplasty surgeons to possess a thorough understanding of how to identify and manage these injuries. Collaborating with an orthopedic traumatologist for assistance with plating the anterior or posterior column, if necessary, can be invaluable. Management options encompass conservative management, revision style acetabular component, screw/plating of anterior/posterior column, and the use of a larger cup with multiple screw augmentation options., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to perform a meta-analysis of randomized controlled trials (RCTs) to compare outcomes following intramedullary nailing (IMN) vs. open reduction-internal fixation (ORIF) for humeral shaft fractures., Methods: A literature search of 3 databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RCTs comparing IMN and ORIF for humeral shaft fractures were included. Clinical outcomes were compared using RevMan. P < .05 was considered statistically significant., Results: Ten RCTs with 512 patients were included. Overall, 8.4% of patients treated with IMN and 6.4% of patients treated with ORIF had nonunion (P = .57, I 2  = 0%), with a significantly faster time to union with IMN (10 weeks vs. 11.9 weeks, P < .05). There was no significant difference in the rate of reoperation (11.6% in IMN group vs. 7.6% in ORIF group, P = .26) or radial nerve palsy (2.8% in IMN group vs. 4.2% in ORIF group, P = .58). A lower rate of infection was noted with IMN (1.2% vs. 5.3%, P < .05). Additionally, there was a lower operative time with IMN (61 minutes vs. 88 minutes, P < .05)., Conclusions: The Level I evidence in the literature does not show a significant difference in rates of union, reoperation, or radial nerve palsy between IMN and ORIF for humeral shaft fractures. Overall, treatment with IMN results in a lower infection rate, less operative time, and a modestly quicker time to union. The optimal treatment strategy for humeral shaft fractures may be best informed by fracture pattern and surgeon preference., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Traumatic extremity amputation can be devastating for patients' functional and psychological health. Challenges of initial management and considerations for limb salvage versus amputation for mangled lower extremities are well documented. However, literature geared toward orthopedic surgeons highlighting management considerations for the residual limb of an amputation is scarce. This article reviews recent literature on management of the residual limb in the perioperative and rehabilitation phases of treatment.

Background Studies demonstrate that metabolic syndrome (MetS) negatively impacts surgical outcomes. This study sought to identify how metabolic syndrome affects outcomes after open reduction and internal fixation (ORIF) of traumatic pilon fractures. Methods Patients who underwent ORIF for pilon fractures from 2012 to 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients with MetS were compared to non-MetS patients for rates of adverse events, prolonged stay, readmission, discharge location, and operative time in the 30-day postoperative period. All statistical analyses were conducted using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Paired student t-tests were used to assess continuous variables. Pearson's Chi-square and odds ratios were used for categorical variables. Results A total of 1,915 patients met this study's inclusion criteria, and 127 MetS patients were identified in the cohort. The MetS cohort was older (62.7 vs 49.5 years old, p-value <0.01), with a greater proportion of female patients (59.1% vs 50.2%, p=0.054). MetS patients experienced significantly higher rates of infectious complications (7.9% vs 3.9% OR 2.75 (CI 1.36-5.53), p=0.008), major adverse events (11% vs 4.3%, OR 2.79 (CI 1.53-5.09) p=0.002), and readmissions. MetS patients also had longer lengths of stay (7 days vs 3.8 days, p-value<0.001), and were more likely to be discharged to a non-home location (51.2% vs 19.5%, p-value<0.01, OR 4.32 (CI=3.0-6.24) p<0.001). Conclusion Patients with MetS have an increased risk of 30-day major complications, infection, readmissions, discharge to a non-home location, and prolonged operative time, and therefore warrant additional consideration for perioperative monitoring., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Panton et al.)

It is important to educate and equip the orthopaedic community with tools to address health care disparities and improve orthopaedic specialty recruitment for racial minorities. How patients and providers are affected by systemic racism in healthcare and what that means in orthopaedic surgery, methods to identify bias and improve access to orthopaedic care for racial minorities, and how to structure a program and department environment to encourage and promote diversity are important topics of discussion.

From the orthopedic trauma surgeon's perspective, successful injury management hinges on fracture fixation and restoration of patient mobility in a safe and expeditious manner. Management of critically injured polytrauma patients and shared decisions regarding regional anesthetics presents a myriad of challenges for orthopedic trauma surgeons and anesthesiologists alike. As the populations age, the typical patient sustaining traumatic orthopedic injuries are increasingly frail and elderly. This trend in demographics has mandated that care for orthogeriatric patients is coordinated by multidisciplinary teams working in concert on medically complex cases to a common end. In this article, we highlight opportunities for improved communication and care integration between orthopedic trauma surgeons and anesthesiologists., Competing Interests: Disclosure None of the authors declared financial, consultant, institutional, or other disclosures related to the research in this article., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: To compare short-term functional outcomes, reduction loss, and rates of surgery for distal radius fractures initially immobilized with a traditional sugar-tong splint versus clamshell splint freeing the elbow., Design: Prospective randomized trial., Setting: Level 1 trauma center., Patients: Eighty-nine consecutive patients sustaining distal radius fractures were enrolled between 2018 and 2020. Short-term first follow-up (1-2 weeks) radiographic parameters and 6 weeks for functional questionnaires were established to assess initial outcomes., Main Outcome Measures: The main outcome measures were reduction loss based on radiographic criteria, rate of surgery, and short-term patient functional outcome using the Disabilities of the Arm, Shoulder, and Hand (DASH) score., Results: There were no differences noted in DASH scores ( P -value = 0.8) or loss of reduction ( P -value = 0.69), and splint type was not correlated with likelihood to have surgery ( P = 0.22). A binomial regression model demonstrated splint type was not a significant predictor variable of loss of fracture reduction in the regression model., Conclusions: These results suggest both sugar-tong splint and clamshell splint construct are acceptable options in the acute management of distal radius fractures., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The first total synthesis of juniperanol, the tricyclic sesquiterpenoid enantiomer of α-cedrol is described. The synthesis relies on stereoselective gold-catalyzed Ohloff-type propargylic ester rearrangement performed on a 10 g scale, and a carbocationic cascade in the presence of acetyl methanesulfonate. The ability of juniperanol to interfere in glucose processes in different cell types is described., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: To determine the efficacy of liposomal bupivacaine compared to placebo for postoperative pain control in patients undergoing operative fixation of ankle fractures., Design: Prospective single-blinded randomized control trial., Setting: Academic Medical Center., Patients/participants: After Institutional Review Board (IRB) approval, 76 patients who sustained an acute ankle fracture (OTA/AO 44A-C) requiring operative fixation met inclusion criteria., Intervention: Patients were randomly assigned to 1 of 2 groups, control (local intraoperative sterile saline injection under general anesthesia) or interventional (local intraoperative liposomal bupivacaine and bupivacaine injection under general anesthesia). Injections were administered in a standardized fashion and included injection of a 1:1 mixture of a 40 mL solution consisting of 1.3% Exparel and sterile saline (interventional) or a 40 mL injection of normal saline (control) into the surrounding periosteal, peritendinous, surrounding muscles and subcutaneous tissue of the surgical incision(s)., Main Outcome Measurements: Pain medications administered and pain according to the Visual Analogue Scale was recorded at scheduled postoperative time points: 4, 24, 48, 72, and 336 hours (14 days)., Results: Thirty-nine patients were randomized to the control group and 37 to the interventional group (mean age = 42 ± 15 years), with no statistically significant differences between groups with regards to severity of injury and patient demographics. Pain scores were significantly lower in the interventional group versus control up to 2 weeks after surgery. Percocet ingestion at 4 hours was significantly lower in the interventional group (0.7 vs. 1.3, P = 0.004), while it approached significance at 48 hours postoperatively (2.8 vs. 3.69, P = 0.07). No other significant differences were noted for Percocet ingestion postoperatively at other time points assessed. The overall satisfaction with pain control was not statistically different between the 2 groups (P = 0.93)., Conclusion: Local intraoperative infiltration of liposomal bupivacaine administered with standard bupivacaine for ankle fractures requiring Open Reduction Internal Fixation (ORIF) affords improved pain relief in the immediate postoperative period resulting in a reduction in Percocet ingestion, with resultant effects seen up to 2 days postoperatively. Continued investigation of this drug for use with extremity fractures is warranted., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background: Despite expansion of interest among American medical students in global health (GH), academic medical centers face multiple obstacles to the development of structured GH curricula and career guidance. To meet these demands we sought to provide a systematic analysis of the accounts of GH experts., Methods: We developed a collaborative, interview-based, qualitative analysis of GH experiences across six career-related themes that are relevant to medical students interested in GH: justification, medical education, economics, research prospects, law and ethics, and work-life balance. Seven GH faculty members were interviewed for 30-90 minutes using sample questions as guidelines. We applied a grounded theory approach to analyze the interview transcripts to discover an emerging theory pertinent to GH trainees., Findings: Regarding justification, 4 respondents defined GH as work with the underserved irrespective of geographic location; 5 respondents found sustainability imperative; and all respondents believe GH creates better physicians. Respondents identified many physician competencies developed through GH medical education, with 5 respondents agreeing that work with underserved populations has transformative potential. Concerning economics, 3 respondents acknowledged GH's popularity among trainees, resulting in increased training opportunities, and 2 respondents emphasized an associated deficiency in program quality. All respondents described career models across specialties. Four respondents noted funding challenges when discussing research prospects. Within the theme of laws and ethics, 4 respondents perceived inadequate accountability, and 6 respondents identified ways to create accountability. Finally, 6 respondents recognized family demands can compromise one's GH career and thus work-life balance., Conclusion: Despite diverse perspectives on the meaning and sustainability of GH work, this analysis provides a nascent framework that may inform curricular development for GH trainees. Suggestions are offered for elaborating this framework to fully exploit the transformative potential of GH training in medical education., (Copyright © 2017 Icahn School of Medicine at Mount Sinai. Published by Elsevier Inc. All rights reserved.)

The purpose is to identify risk factors of functional outcome following proximal humerus open reduction and internal fixation. Patients treated for proximal humerus fractures with open reduction and internal fixation were enrolled in a prospective data registry. Patients were evaluated for function using the Disability of the Arm, Shoulder and Hand score for 12 months and as available beyond 12 months. Univariate analyses were conducted to identify variables associated with functional outcome. Significant variables were included in a multivariate regression predicting functional outcome. Demographics and minimum of 12 month follow-up were available for 129 patients (75%). Multiple regression demonstrated postoperative complication (B=8.515 p=0.045), education level (B=-6.269p<0.0005), age (B=0.241p=0.049) and Charlson Comorbidity Index (B=6.578, p=0.001) were all significant predictors of functional outcome. Orthopaedic surgeons can use education level, comorbidities, age, and postoperative complication information to screen patients for worse outcomes, establish expectations, and guide care.

Introduction: The purpose of this study was to assess 1-year outcomes of patients with displaced proximal humerus fractures who underwent treatment with locked plate fixation with rotator cuff suture augmentation., Methods: A total of 86 patients who had sustained 2, 3 and 4-part displaced proximal humerus fractures underwent locked plate fixation with multiple sutures placed in the cuff tendons. Clinical outcome variables included active forward elevation (AFE), active external rotation (AER), and Constant and American Shoulder and Elbow Surgeons (ASES) scores. Post-operative variables included the following complications: varus re-collapse, loss of fixation, osteonecrosis of the humeral head (AVN), screw cut out, hardware failure and infection., Results: Forty-one patients were available with minimum of 1-year follow-up. Mean AFE was 142±17.0° and AER was 41±13.0°. The overall complication rate was 14.6%, with osteonecrosis being the most common (12.2%). Of the 21 patients (51.2%) that initially had varus displacement, all but one maintained anatomic reduction and fixation. Mean ASES score was 78.2±20.0 and average Constant score was 72.7±17.6. Bivariate analyses demonstrated that pre-operative medial comminution (p=0.297) or varus collapse (p=0.95) were not associated with an increased likelihood of sustaining a complication., Conclusions: Follow-up of patients in this series demonstrated a low overall complication rate and excellent functional outcomes. We believe suture augmentation of the rotator cuff can counteract varus forces on proximal humerus fractures fixed with locked plates, and should be performed routinely in displaced 2, 3 and 4 part fractures., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Recent nanofluidic experiments revealed strongly different surface charge measurements for boron-nitride (BN) and graphitic nanotubes when in contact with saline and alkaline water (Nature 2013, 494, 455-458; Phys. Rev. Lett. 2016, 116, 154501). These observations contrast with the similar reactivity of a graphene layer and its BN counterpart, using density functional theory (DFT) framework, for intact and dissociative adsorption of gaseous water molecules. Here we investigate, by DFT in implicit water, single and multiple adsorption of anionic hydroxide on single layers. A differential adsorption strength is found in vacuum for the first ionic adsorption on the two materials-chemisorbed on BN while physisorbed on graphene. The effect of implicit solvation reduces all adsorption values, resulting in a favorable (nonfavorable) adsorption on BN (graphene). We also calculate a pK a ≃ 6 for BN in water, in good agreement with experiments. Comparatively, the unfavorable results for graphene in water echo the weaker surface charge measurements but point to an alternative scenario.

Supercapacitors are electrochemical devices which store energy by ion adsorption on the surface of a porous carbon. They are characterized by high power delivery. The use of nanoporous carbon to increase their energy density should not hinder their fast charging. However, the mechanisms for ion transport inside electrified nanopores remain largely unknown. Here we show that the diffusion is characterized by a hierarchy of time scales arising from ion confinement, solvation, and electrosorption effects. By combining electrochemistry experiments with molecular dynamics simulations, we determine the in-pore conductivities and diffusion coefficients and their variations with the applied potential. We show that the diffusion of the ions is slower by 1 order of magnitude compared to the bulk electrolyte. The desolvation of the ions occurs on much faster time scales than electrosorption.

Background and Objectives: This study describes characteristics and the evolution of the careers of graduates from a 1-year post-residency fellowship program whose primary objectives included clinical skills in Cesarean section. Besides obstetrical practice, rural service and attainment of faculty appointment were used as surrogate measures of fulfilling an underserved need for family medicine obstetrics., Methods: For 18 years, the authors maintained contact with all 80 physicians completing 1-year fellowships in family medicine obstetrics in Memphis and Nashville. The founding chair of these programs surveyed each physician and maintained a network of contacts to study outcomes such as graduation, service location, hospital privileges, retention, and career changes., Results: The study tracked 100% of the sample and documented high rates of fellowship completion (74/80 [93%]), Cesarean privileges (71/74 [96%]), and service in a rural community for at least 2 years (47/74 [64%]). The fellowship was also associated with participation as faculty (36/74 [46%])., Conclusions: This paper produces the first and longest-term data describing attrition over time and examines the reasons why fellowship-trained family physicians stop doing maternity care. It is the only series with a 100% response rate and provides longitudinal data on the outcomes of these fellowship programs. Attrition was highest at rural sites. Workforce planners and fellowship designers might benefit from these considerations.

The authors present a case of post-traumatic fat embolus, which was remarkable by the very haemorrhagic nature of the pulmonary oedema, which healed without sequel.