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AIM: Although nonunions are among the most common complications after long-bone fracture fixation, the definition of fracture nonunion remains controversial and varies widely. The aim of this study was to identify the definitions and diagnostic criteria used in the scientific literature to describe nonunions after long-bone fractures. METHODS: A comprehensive literature search was performed in PubMed, Cochrane Library, Web of Science, and Embase. Prospective clinical studies, in which adult long-bone fracture nonunions were investigated as main subject, were included in this analysis. Data on nonunion definitions described in each study were extracted and collected in a database. RESULTS: Although 148 studies met the inclusion criteria, only 50% (74/148) provided a definition for their main study subject. Nonunion was defined in these studies based on time-related criteria in 85% (63/74), on radiographic criteria in 62% (46/74), and on clinical criteria in 45% (33/74). A combination of clinical, radiographic and time-related criteria for definition was found in 38% (28/74). The time interval between fracture and the time point when authors defined an unhealed fracture as a nonunion showed considerable heterogeneity, ranging from three to twelve months. CONCLUSION: In the current orthopaedic literature, we found a lack of consensus with regard to the definition of long-bone nonunions. Without valid and reliable definition criteria for nonunion, standardization of diagnostic and treatment algorithms as well as the comparison of clinical studies remains problematic. The lack of a clear definition emphasizes the need for a consensus-based approach to the diagnosis of fracture nonunion centred on clinical, radiographical and time-related criteria. pmid: 34531088 ispartof: INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED vol:52 issue:11 pages:3200-3205 ispartof: location:Netherlands status: published

Posttraumatic osteoarthritis (PTOA) significantly affects patients with pilon fractures even after adequate anatomical reduction, and treatment strategies targeting the biologic mediators of PTOA are needed. This study was designed to determine the effects of intra-articular injection of platelet-rich plasma (PRP) on synovial fluid (SF) biomarkers for patients undergoing open reduction and internal fixation (ORIF) of pilon fractures. Patients undergoing staged management of pilon fractures were enrolled in a prospective, double-blinded, randomized, and placebo-controlled clinical trial to determine the effects of a single intra-articular injection of leukocyte-reduced PRP on SF biomarkers. Arthrocentesis of the injured and uninjured ankles was performed at the time of external skeletal fixation (ESF) and ORIF. Patients were randomized to receive either autogenous leukocyte-reduced PRP or saline (control) via intra-articular injection into the injured ankle at the time of ESF. SF biomarker concentrations were compared-uninjured, injured pretreatment, and saline-injected or PRP-injected. Eleven patients (PRP, n = 5; saline, n = 6) completed the study. Twenty-one uninjured, and 11 injured pretreatment, five PRP-treated, and six saline-treated SF samples were analyzed. PRP-treated SF contained significantly higher levels of PDGF-AA (p = 0.046) and significantly lower levels of MMP-3 (p = 0.042), MMP-9 (p = 0.009), IL-1β (p = 0.049), IL-6 (p < 0.01), IL-8 (p = 0.048), and PGE2 (p < 0.04). This study provided mechanistic data to suggest that a single intraarticular injection of leukocyte-reduced PRP is associated with anti-inflammatory, anti-degradative, and anabolic responses compared with saline control. These findings provide the impetus for investigating long-term clinical outcomes after PRP injection as an orthobiologic adjunct to ORIF for mitigating the incidence and severity of PTOA after pilon fractures.

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.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.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).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.US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.

Objectives The objectives of this study are to present a new method of quantifying variability in human femoral geometry and to use this data to optimize intramedullary nail geometry for a better fit within the femoral canal. Methods Computed tomography (CT) scans of forty intact adult human femora were divided according to race, sex, and age, and were reconstructed digitally into three-dimensional solid models. Geometric features were then measured and compared among groups using ANOVA. An average geometric model was generated, from which an optimal intramedullary (IM) nail curvature function was derived. Insertion of the derived optimal nail and of two currently-available commercial nails into the femur having the highest degree of curvature was then simulated via finite element methods. Results Substantial variability in femoral curvature was observed among the population sample. Sex was found to correlate most strongly with femoral size; males tend to have larger femora than females. Although the average femoral radius of curvature for African Americans was slightly higher than for Caucasians, the difference was not statistically significant. Curvature did not vary across the sample by age, sex or race. Finite element analysis results simulating IM nail insertion using the geometrically-optimized nail showed a substantial decrease in von Mises stress when compared to tested commercially-available IM nails. Fracture was predicted within the posterior canal wall for commercially available nails, as the generated stresses exceeded the allowable stress of cortical bone, but not for the geometrically-optimized nail. Conclusions Considering variation in femoral geometry among patients when designing implantable fixation devices may be important. Femoral size differs between adults by sex, with males being larger than females. Pattern of curvature, however, did not differ, although there may be slight differences between European and African Americans. As such, the proposed average femoral curvature function calculated here may be sufficient for the entire population. According to finite element analysis, insertion-induced stresses in the femur were within the allowable range for the geometrically-optimized nail and appear more desirable than in other common nail designs.

Background Multiple small relaxing skin incisions oriented parallel to the longitudinal axis (so-called "pie-crusting") near traumatic lacerations or surgical incisions in edematous tissue beds have been utilized to achieve primary closure when edema or skin loss would otherwise have made this difficult. Our study hopes to demonstrate (1) biomechanical evidence that pie-crusting decreases wound closure tension and (2) provide a case series with data showing clinical results. Materials and methods This study is a biomechanical cadaveric study and retrospective small series cohort using 16 porcine limbs and 7 patients with 8 wounds in which pie-crusting was performed. An elliptical incision was made on the porcine limbs and the wound closure tension was measured with a hydraulic test machine before and after pie-crusting. The retrospective patient cohort had pie-crusting performed on traumatic wounds that were difficult to primarily close. The patient cohort was assessed by retrospective chart review examining wound dimensions before and after pie-crusting, and wound healing at final follow-up. Results The biomechanical data showed that pie-crusting the wound with both a single and double row of incisions significantly decreased the closing tension. A single row decreased wound tension by an average of 34%. Using an average of 3.5 parallel layers of pie-crusting at the time of definitive closure all wounds in the patient cohort closed and healed well with no complications at average follow-up (average 18 months). Conclusion Pie-crusting may allow for easier wound closure and decrease the need for skin-grafting in edematous extremity wounds, with minimal patient morbidity.

» Radial head arthroplasty is a viable surgical option when a radial head fracture cannot be reconstructed. Radial head arthroplasty provides a load-bearing articular structure against the capitellum in unstable fractured elbows. » Studies have emphasized the importance of choosing the correct implant size to replicate the native radial head anatomy, citing various consequences of improperly sized radial head prostheses. Overstuffing of the radiocapitellar joint, or lengthening of the radius, has been extensively studied because of its detrimental effects on elbow biomechanics, but other types of improper sizing also have negative consequences. » In the setting of severe fracture-dislocation or revision surgery, anatomic landmarks that are useful for prosthesis sizing often are missing. Various methods have been described to provide guidance for the accurate sizing of a prosthetic radial head; a retrieved radial head, the proximal edge of the lesser sigmoid notch, the radiocapitellar synovial fold, and the ulnohumeral joint space all represent useful references. » Intraoperative radiographic examination is an important step while assessing implant size, including the height of the prosthetic radial head. » Since no single method is perfect on its own, the surgeon should combine as many reference measures as possible, both before and during the procedure, for accurate prosthesis sizing in order to achieve successful outcomes.

Objective To assess whether the fixation method and vitamin D supplementation affect the risk of patient-important outcomes within 12 months of injury in nongeriatric femoral neck fracture patients. Design A pilot factorial randomized controlled trial. Setting Fifteen North American clinical sites. Participants Ninety-one adults 18-60 years of age with a femoral neck fracture requiring surgical fixation. Intervention Participants were randomized to a surgical intervention (sliding hip screw or cancellous screws) and a vitamin D intervention (vitamin D3 4000 IU daily vs. placebo for 6 months). Main outcome measurements The primary clinical outcome was a composite of patient-important complications (reoperation, femoral head osteonecrosis, severe femoral neck malunion, and nonunion). Secondary outcomes included fracture-healing complications and radiographic fracture healing. Results Eighty-six participants with a mean age of 41 years were included. We found no statistically significant difference in the risk of patient-important outcomes between the surgical treatment arms (hazard ratio 0.90, 95% confidence interval 0.40-2.02, P = 0.80) and vitamin D supplementation treatment arms (hazard ratio 0.96, 95% confidence interval 0.42-2.18, P = 0.92). Conclusions These pilot trial results continue to describe the results of current fixation implants, inform the challenges of improving outcomes in this fracture population, and may guide future vitamin D trials to improve healing outcomes in young fracture populations. Although the pilot trial was not adequately powered to detect treatment effects, publishing these results may facilitate future meta-analyses on this topic. Level of evidence Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Copyright © 2018 by the American Society of Plastic Surgeons. Background: Soft-tissue complications often dictate the success of limb salvage and the overall outcome of open fractures. Based on prior work at the R Adams Cowley Shock Trauma Center, the authors hypothesize that wounds larger than 200 cm2 are associated with a greater likelihood of both flap-related reoperation and wound complications among patients requiring soft-tissue reconstruction with a rotational flap or free tissue transfer. Methods: This study was a secondary analysis of Fluid Lavage in Open Wounds trial data that included all patients who received a rotational or free tissue flap transfer for an open fracture. The primary outcome was flap-related reoperation within 12 months of injury. The secondary outcome was wound complication, which included events treated operatively or nonoperatively. Multivariable logistic regression was used to assess the association between wound size and outcomes, adjusting for confounders. Results: Seventeen percent of the 112 patients required a flap-related reoperation. A wound size greater than 200 cm2 was not associated with reoperation in an unadjusted model (p = 0.64) or adjusting for Gustilo type (p = 0.70). The sample had an overall wound complication rate of 47.3 percent. Patients with a wound size of greater than 200 cm2 were three times more likely to experience wound complications (OR, 3.05; 95 percent CI, 1.08 to 8.62; p = 0.04) when adjusting for moderate to severe wound contamination and wound closure in the operating room. Conclusion: The findings of this study demonstrate that wound surface area is an integral determinant for wound complication following soft-tissue flap treatment, but found no association between wound surface area and flap-related reoperation rates.

Orthopaedic surgeons commonly have the misconception that patients with tibial plateau fractures will likely go on to posttraumatic knee arthritis requiring total knee arthroplasty (TKA). In younger patients, osteochondral allograft (OCA) transplantation is an alternative method to address posttraumatic knee arthritis. The purpose of this study was (1) to identify our institutional failure rate following tibial plateau open reduction and internal fixation (ORIF) (failure was defined as conversion to TKA or OCA); (2) to determine if there are patient- or injury-related risk factors predictive of failure; and (3) to characterize differences between patients treated with TKA versus those treated with OCA transplantation. A 10-year retrospective review was conducted to identify patients treated at our institution with a tibial plateau fracture. Patients included in the final analysis were at least 18 years of age with an articular fracture (AO/OTA 41 B/C). The primary outcome was subsequent ipsilateral OCA or TKA. There were 350 patients (359 tibial plateau fractures) with a mean follow-up of 22.3 months (range, 6–133 months) who met inclusion criteria. Twenty-seven fractures (7.5%) were subsequently converted to a TKA or OCA at an average of 3.75 ± 3.1 years following their initial surgery. Patients who consumed tobacco were 2.3 times more likely to require a joint replacement (confidence interval [CI], 1.0–5.2; p = 0.04). Those patients who received an OCAs were significantly younger as compared with their TKA peers, both at time of initial injury (37 vs. 51 years, p = 0.02) and at time of surgery (41 vs. 55 years, p = 0.009). The joint replacement rate in this study is similar to those studies in the published literature that focused solely on the prevalence of conventional TKA. Tobacco is a risk factor for failure following tibial plateau ORIF. Patients who were treated with an OCA were younger at time of injury and failure.

OBJECTIVES The purpose of this study was to review the treatment of patients with ipsilateral acetabular and femur fractures to provide descriptive demographic data, injury pattern classification, treatment, and evaluate the complication profile reflective of current practices. STUDY DESIGN Multicenter retrospective cohort. SETTING Eight Level 1 Trauma Centers. PATIENTS/PARTICIPANTS One hundred one patients met inclusion criteria. INTERVENTION Surgical treatment of both the acetabular and femur fractures. MAIN OUTCOME MEASUREMENTS The complications evaluated include avascular necrosis, heterotopic ossification, posttraumatic arthritis, deep venous thrombosis, pulmonary embolism and superficial/deep infection, fracture union, and secondary surgeries. RESULTS Forty-three patients had 31 type fractures (29A; 11B, and 3C), 60 had 32 type (37A, 8B; 15C), and 8 had 33 type (1A, 4B, 3C) femur fractures; 10 patients had combinations involving more than 1 femur fracture pattern. There were 35 62A type fractures, 47 62B, and 19 62C acetabular fractures. Age of 45 or older was associated with marginal impaction (P = 0.001). The aggregate infection rate was 17%. More than 30% of patients required secondary surgeries. The rate of avascular necrosis was higher in acetabular fractures combined with proximal femur fractures (P < 0.05). The rate of deep venous thrombosis was associated with increased age and time to surgical fixation (P < 0.05). CONCLUSIONS We report the largest review of the surgical treatment and complications of ipsilateral acetabular and femoral fractures. This study provides useful information regarding the complications and provides some treatment recommendations regarding these injuries. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background The study purpose is to evaluate the working length, proximal screw density, and diaphyseal fixation mode and the correlation to fracture union after locking plate osteosynthesis of distal femoral fractures using bridge-plating technique. Methods A four-year retrospective review was performed to identify patients undergoing operative fixation of distal femur fractures with a distal femoral locking plate using bridge-plating technique for the metadiaphyseal region. Primary variables included fracture union, secondary surgery for union, plate working length, and diaphyseal screw technique and configuration. Multiple secondary variables including plate metallurgy and coronal plane fracture alignment were also collected. Results Ninety-six patients with distal femur fractures with a mean age 60 years met inclusion criteria. None of the clinical parameters were statistically significant indicators of union. Likewise, none of the following surgical technique parameters were associated with fracture union: plate metallurgy, the mean working length, screw density and number of proximal screws and screw cortices. However, diaphyseal screw technique did show statistical significance. Hybrid technique had a statistically significant higher chance of union when compared to locking (p = 0.02). All proximal locking screw constructs were 2.9 times more likely to lead to nonunion. Conclusions Plating constructs with all locking screws used in the diaphysis when bridge-plating distal femur locking plates were 2.9 times more likely to incur a nonunion. However, other factors associated with more flexible fixation constructs such as increased working length, decreased proximal screw number, and decreased proximal screw density were not significantly associated with union in this study.

Background Negative pressure wound therapy use over closed surgical incisions (iNPWT) has proven to be effective at reducing hematoma, wound drainage and infection in high-risk wounds. The purpose of this study was to determine if iNPWT decreased the risk of infection in patients undergoing open reduction internal fixation (ORIF) for acetabular fractures. Methods 71 patients who underwent operative intervention for an acetabular fracture between March 2008 and September 2012 consented and prospectively randomized to iNPWT or a standard postoperative (dry gauze) dressing. The primary endpoint was deep infection, i.e. necessitating surgical debridement. Patients were followed until fracture union. Results 33 patients were randomized to treatment with a standard gauze dressing and 33 patients were randomized to the iNPWT cohort. There were no statistically significant differences between the groups with respect to patient demographics, clinical, or surgery characteristics. Overall, seven patients (10.6%) were diagnosed with infections; two patients (6.1%) in the placebo group and 5 (15.2%) in the treatment group. Conclusions In this randomized prospective trial, iNPWT did not decrease the incidence of deep infections when compared to gauze dressings in patients with acetabular fractures. Although not statistically significant, patients in the iNPWT cohort were 2.77 times more likely to develop a deep infection.

BackgroundFracture nonunion risk is related to severity of injury and type of treatment, yet fracture healing is not fully explained by these factors alone. We hypothesize that patient demographic factors assessable by the clinician at fracture presentation can predict nonunion.MethodsA prospective cohort study design was used to examine ~2.5 million Medicare patients nationwide. Patients making fracture claims in the 5% Medicare Standard Analytic Files in 2011 were analyzed; continuous enrollment for 12months after fracture was required to capture the ICD-9-CM nonunion diagnosis code (733.82) or any procedure codes for nonunion repair. A stepwise regression analysis was used which dropped variables from analysis if they did not contribute sufficient explanatory power. In-sample predictive accuracy was assessed using a receiver operating characteristic (ROC) curve approach, and an out-of-sample comparison was drawn from the 2012 Medicare 5% SAF files.ResultsOverall, 47,437 Medicare patients had 56,492 fractures and 2.5% of fractures were nonunion. Patients with healed fracture (age 75.0±12.7SD) were older (p

Ongoing studies investigating fracture healing have uncovered and allowed investigators to gain a better understanding of where the variety of cells, which participate in this process, originate, and how they communicate as well as how they can be enhanced to successfully heal a fracture when the process has slowed or failed completely. This brief review will highlight some of the recent findings regarding the role the immune system in fracture healing and how these cells communicate with each other during the healing process. In addition, two 2 methods that have recently been shown to be promising techniques in supporting fracture when it stalls or reversing the process, when the fracture has failed to heal, will also be described.

Objective To assess the "Dedicated Orthopaedic Trauma Operating Room" (DOTOR) effect on management and outcomes of open tibia and femur fractures. Design Retrospective chart review. Location University Level I Trauma Center. Methods Patients categorized into those managed in the DOTOR versus those managed in a standard on-call operating room (OCOR). Data collected include patient and injury characteristics, time to debridement, and patient outcomes. Results A total of 297 patients with 347 open tibia and femur fractures were included; 154 patients (174 fractures) were managed in the DOTOR group and 143 patients (170 fractures) were managed in the OCOR group. The average time to debridement was significantly longer for DOTOR (12.9 hours) versus OCOR (5.4 hours). The DOTOR group was 9 times less likely to undergo debridement within 6 hours. The number of patients debrided within 24 hours was similar (90% for DOTOR vs. 96% OCOR). The rate of primary fracture union was significantly higher in the DOTOR (73.2% vs. 56.6%). OCOR patients were twice as likely to have an unplanned surgery. Rates of infection, nonunion, and amputation were similar. Conclusion Despite earlier access to the Operating room for debridement in the OCOR group, there was no difference in the infection rate compared with the DOTOR group. However, patients managed in the DOTOR group were more likely to go on to uncomplicated fracture union and less likely to have an unplanned surgery. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The importance of timely pre-operative antibiotic agents for effective surgical prophylaxis has been established but the optimal duration of antimicrobial coverage post-operatively has not yet been defined clearly. The purpose of this study was to determine if prophylactic post- operative cefazolin for 23 hours decreases the risk of surgical site infection (SSI) after open reduction internal fixation (ORIF) of closed extremity fractures.After Institutional Reviews Board approval, patients undergoing ORIF of closed extremity fractures who had a planned post-operative stay of at least 23 hours were randomly assigned to either receive 23 hours of cefazolin or a placebo. Both groups received weight-based pre-operative cefazolin and intra-operative re-dosing at three-hour intervals until surgery completion. The primary end point was infection. Patients were followed clinically until bony union. Published risk factors were accumulated as a risk score to help determine risk of SSI.A total of 227 patients were randomized to either receive post-operative cefazolin or placebo and 160 patients completed clinical follow-up to bony union. There were 83 patients in the cefazolin group and 77 in the placebo group. Surgical site infections occurred in a total of 15 patients (9.4%) in this trial without any differences between the cefazolin and placebo groups. Patients with diabetes mellitus were 4.33 times more likely to develop an SSI (95% confidence interval [CI], 1.30-14.38; p = 0.02). Patients with a risk score of two or more were 3.14 times more likely to develop an infection (95% CI, 1.02-9.68; p 0.05).Although not statistically significant, in a randomized double-blinded placebo-controlled trial, patients who were treated with a 23-hour post-operative regimen of antibiotics after ORIF were less likely to develop SSIs. Patients with diabetes mellitus and those with a risk score of two or greater were more likely to develop an SSI.

Certain common medications are associated with an elevated risk of fracture and recent data suggests that medications can also increase nonunion risk. Medication use is a modifiable nonunion risk factor, but it is unknown whether risk accrues solely to chronic medication use or whether there is also risk inherent to acute use.Multivariate logistic regression was used in an inception cohort to calculate odds ratios (OR) for fracture nonunion associated with medication use, in context with other risk factors demonstrated to influence nonunion. Patient-level health claims for medical and drug expenses were compiled from a payer database. Patients were included if they had a fracture coded in 2011, with continuous enrollment for 1 month prior to and 12 months after fracture. The database contained demographic descriptors, treatment procedures per CPT codes, co-morbidities per ICD-9 codes, and prescriptions per National Drug Codes. Chronic medication use was defined as ≥30 days of prescription prior to fracture with ≥1 day afterward; acute use was any other prescription.Most non-analgesic medications were safe in acute or chronic use, but risk of nonunion was elevated for a wide range of analgesics. Overall, 45,085 fractures (14.6% of fractures) affected patients using chronic opioids. Nonunion OR was elevated for acute and chronic use of Schedule 2 opioids including acetaminophen/oxycodone, hydromorphone, oxycodone, and acetaminophen/hydrocodone bitartrate, as well as Schedule 3-5 opioids including tramadol (all, p 0.0001). The highest ORs were associated with chronic administration of Schedule 2 opioids.Most medications do not increase nonunion risk, but acute and chronic use of NSAIDs or opioids was associated with impaired fracture healing. There is particular risk in prescribing opioid analgesics for fracture, though literature suggests that roughly half of opioid-naïve patients receive such a prescription.Patients evaluated in this study were not a random sample of Americans; they may approximate a random sample of the Emergency Department population in the United States. Thus, trauma patients may represent a population enriched for nonunion risk factors. Opioids impair recovery from injury; if they also predispose to injury, the ongoing opioid epidemic could presage an increase in nonunion prevalence.

OBJECTIVE The purpose of this study was to determine the effectiveness of our vitamin D treatment protocol in managing low serum vitamin D levels in orthopaedic trauma patients. METHODS A retrospective review was conducted of all orthopaedic trauma patients at a university level I trauma center over 20 months. Patients were included if they had an initial and repeat 25-hydroxy (OH) vitamin D serum level available. Vitamin D deficiency was defined as serum 25-hydroxy vitamin D level with less than 20 ng/mL. Vitamin D insufficiency was defined as serum 25-hydroxy vitamin D level between 20 and 32 ng/mL. The standard regimen for all patients was over-the-counter vitamin D3 1000 IU and 1500 mg of calcium daily. Patients with vitamin D deficiency or insufficiency also received 50,000 IU of ergocalciferol (D2) weekly until their 25-hydroxyvitamin D level normalized or their fracture healed. No compliance monitoring was performed except for questioning at each clinic visit. RESULTS A total of 201 patients met the inclusion criteria. Thirty-two patients had a normal initial 25-hydroxyvitamin D level, and 84% maintained their normal level, whereas 16% became insufficient or deficient. There were 88 patients insufficient initially and 54.5% improved to normal and 8% became deficient. In the vitamin D deficiency group (81), 26% remained deficient and 74% improved to insufficient. The average increase in serum 25-OH vitamin D with treatment (in nanograms per milliliter) was statistically significant for both the insufficient and deficient groups. CONCLUSIONS Vitamin D therapy improved the majority of the patients' vitamin D-25-OH level but did not normalize most. Patients with initial deficiency had the largest improvement. This study indicates that vigilance is required to adequately treat a low serum vitamin D-25-OH level.

The epidemiology of fracture nonunion has been characterized so it is potentially possible to predict nonunion using patient-related risk factors. However, prediction models are currently too cumbersome to be useful. We test a hypothesis that nonunion can be predicted with ≤10 variables, retaining the predictive accuracy of a full model with 42 variables.We sought to predict nonunion with prospectively-acquired inception cohort data for 18 different bones, using the smallest possible number of variables that did not substantially decrease prediction accuracy. An American nationwide claims database of ∼90.1 million participants was used, which included medical and drug expenses for 2011-2012. Continuous enrollment was required for 12 months after fracture, to allow sufficient time to capture a nonunion diagnosis. Health claims were evaluated for 309,330 fractures. A training dataset used a random subset of 2/3 of these fractures, while the remaining fractures formed a validation dataset. Multivariate logistic regression and stepwise logistic regression were used to identify variables predictive of nonunion. P value and the Akaike Information Criterion (AIC) were used to select variables for reduced models. Area-under-the-curve (AUC) was calculated to characterize the success of prediction.Nonunion rate in 18 fracture locations averaged 4.93%. Algorithms to predict nonunion in 18 locations in the full-model validation set had average AUC=0.680 (±0.034). In the reduced models, average validation set AUC=0.680 (±0.033) and the average number of risk factors required for prediction was 7.6. There was agreement across training set, validation set, and reduced set; in tibia, reduced model validation AUC=0.703, while the full-model validation AUC=0.709. Certain risk factors were important for predicting nonunion in ≥10 bones, including open fracture, multiple fracture, osteoarthritis, surgical treatment, and use of certain medications, including anticoagulants, anticonvulsants, or analgesics.Nonunion can be predicted in 18 fracture locations using parsimonious models with10 patient demography-related risk factors. The model reduction approach used results in simplified models that have nearly the same AUC as the full model. Reduced algorithms can predict nonunion because risk factors important in the full models remain important in the reduced models. This prognostic inception cohort study provides Level I evidence.

OBJECTIVE The clinical value of low-intensity pulsed ultrasound (LIPUS) for fresh fracture is known. Yet, in the absence of a definition of what "fresh" is, payers have adopted study inclusion criteria drawn from randomized clinical trials as de facto definitions of which patients should be treated, with "fresh" defined as

© 2017 Elsevier Ltd Background Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. Methods For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Findings Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0·83, 95% CI 0·63–1·09; p=0·18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1·91, 1·06–3·44; p=0·0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0·82; appendix); these events included pulmonary embolism (two patients [

Loss of contact between radial head fracture fragments is strongly associated with other elbow or forearm injuries. If this finding has adequate interobserver reliability, it could help examiners identify and treat associated ligament injuries and fractures (eg, forearm interosseous ligament injury or elbow dislocation). (1) What is the interobserver agreement on radiographic loss of contact between radial head fracture fragments? (2) Are there factors associated with the observer such as location of practice or subspecialization that increase interobserver reliability? Fully trained practicing orthopaedic and trauma surgeons from around the world evaluated 27 anteroposterior and lateral radiographs of radial head fractures on a web-based platform for the following characteristics: (1) loss of contact between at least one radial head fracture fragment and the remaining radial head and neck; (2) a gap between fragments of 2 mm or greater; (3) anticipated fracture instability (mobility) on operative exposure; (4) anticipated associated ligament injuries; and (5) recommendation for treatment. Agreement among observers was measured using the multirater kappa measure. Kappas for various observer characteristics were compared using 95% confidence intervals. The overall interobserver agreement was moderate (range, 0.49-0.55) for each question except associated ligament injury, which was fair (0.33). Shoulder and elbow surgeons had substantial agreement (range, 0.51-0.61) in many areas, but kappas were generally in the moderate range (0.41-0.59) based on number of years in practice, radial head fractures treated per year, and trainee supervision. Radiographic signs of radial head fracture instability such as loss of contact have moderate reliability. This characteristic seems clinically useful, because loss of contact between at least one radial head fracture fragment and the remaining radial head and neck is strongly associated with associated ligament injury or other fractures. Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence

Low levels of serum vitamin D have been linked to numerous musculoskeletal and nonmusculoskeletal conditions. Vitamin D deficiency appears relatively high among various patient subpopulations, including patients with fracture nonunion. We conducted a retrospective study to determine the prevalence of vitamin D deficiency and insufficiency in a large population of patients with orthopedic trauma. The study included all patients who were over age 18 years, had no risk factors for vitamin D deficiency, and were treated for an acute fracture at a Level 1 trauma center. Between January 2009 and September 2010, 889 trauma patients had recorded serum 25-hydroxyvitamin D levels. Overall prevalence of combined vitamin D deficiency/insufficiency was 77%; prevalence of vitamin D deficiency alone was 39%. There were no statistically significant (P.05) age or sex differences among the population. There did not appear to be a seasonal difference. Vitamin D deficiency and insufficiency in acute orthopedic trauma patients appear very common. Further investigation is needed to fully understand the clinical significance.

One in 50 women presenting to an orthopaedic clinic with an injury have been injured from intimate partner violence (IPV). This number does not include the additional patients who have experienced psychological or emotional abuse. Musculoskeletal injuries, such as fractures, sprains, strains, and dislocations, are the second-most prevalent injury type after head and neck injuries that occur after physical violence. Therefore, it is incumbent on health-care workers who provide care in fracture clinics to recognize musculoskeletal manifestations of IPV. Given the serial follow-up assessments for routine fracture care, orthopaedic surgeons are uniquely positioned to provide assistance to these patients. Escalating violence is the single greatest predictor of intimate partner homicide. Identification of patients at risk for IPV and provision of resources beyond their orthopaedic needs may reduce ongoing harm to our patients.

Displaced patella fractures often result in disruption of the extensor mechanism of the knee. An intact extensor mechanism is a requirement for unassisted gait. Therefore, operative treatment of the displaced patella fracture is generally recommended. The evaluation of the patella fracture patient includes examination of extensor mechanism integrity. Operative management of patella fractures normally includes open reduction with internal fixation, although partial patellectomy is occasionally performed, with advancement of quadriceps tendon or patellar ligament to the fracture bed. Open reduction with internal fixation has historically been performed utilizing anterior tension band wiring, although comminution of the fracture occasionally makes this fixation construct inadequate. Supplementation or replacement of the tension band wire construct with interfragmentary screws, cerclage wire or suture, and/or plate-and-screw constructs may add to the stability of the fixation construct. Arthrosis of the patellofemoral joint is very common after healing of patella fractures, and substantial functional deficits may persist long after fracture healing has occurred.

Objective To determine whether low intensity pulsed ultrasound (LIPUS), compared with sham treatment, accelerates functional recovery and radiographic healing in patients with operatively managed tibial fractures. Design A concealed, randomized, blinded, sham controlled clinical trial with a parallel group design of 501 patients, enrolled between October 2008 and September 2012, and followed for one year. Setting 43 North American academic trauma centers. Participants Skeletally mature men or women with an open or closed tibial fracture amenable to intramedullary nail fixation. Exclusions comprised pilon fractures, tibial shaft fractures that extended into the joint and required reduction, pathological fractures, bilateral tibial fractures, segmental fractures, spiral fractures >7.5 cm in length, concomitant injuries that were likely to impair function for at least as long as the patient’s tibial fracture, and tibial fractures that showed 1 cm gap after surgical fixation. 3105 consecutive patients who underwent intramedullary nailing for tibial fracture were assessed, 599 were eligible and 501 provided informed consent and were enrolled. Interventions Patients were allocated centrally to self administer daily LIPUS (n=250) or use a sham device (n=251) until their tibial fracture showed radiographic healing or until one year after intramedullary fixation. Main outcome measures Primary registry specified outcome was time to radiographic healing within one year of fixation; secondary outcome was rate of non-union. Additional protocol specified outcomes included short form-36 (SF-36) physical component summary (PCS) scores, return to work, return to household activities, return to ≥80% of function before injury, return to leisure activities, time to full weight bearing, scores on the health utilities index (mark 3), and adverse events related to the device. Results SF-36 PCS data were acquired from 481/501 (96%) patients, for whom we had 2303/2886 (80%) observations, and radiographic healing data were acquired from 482/501 (96%) patients, of whom 82 were censored. Results showed no impact on SF-36 PCS scores between LIPUS and control groups (mean difference 0.55, 95% confidence interval −0.75 to 1.84; P=0.41) or for the interaction between time and treatment (P=0.30); minimal important difference is 3-5 points) or in other functional measures. There was also no difference in time to radiographic healing (hazard ratio 1.07, 95% confidence interval 0.86 to 1.34; P=0.55). There were no differences in safety outcomes between treatment groups. Patient compliance was moderate; 73% of patients administered ≥50% of all recommended treatments. Conclusions Postoperative use of LIPUS after tibial fracture fixation does not accelerate radiographic healing and fails to improve functional recovery. Study registration ClinicalTrialGov Identifier: [NCT00667849][1] [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00667849&atom=%2Fbmj%2F355%2Fbmj.i5351.atom

Many risk factors for fracture nonunion are well supported in the orthopaedic literature, including location of the fracture site, surgical treatment, bone displacement, type of fixation, treatment delay, comminution, inadequate treatment, and wound infection. However, evidence from a systematic review suggests that patient-related or biological causes of nonunion may not be as well understood. Understanding the biological causes of nonunion is important for several reasons. Risk factors might identify patients prone to nonunion who could benefit from more aggressive intervention, and a clear idea of nonunion risk could be important when choosing between competing therapeutic options. Risk factors also can inform the design of clinical trials and clarify patient inclusion and exclusion criteria, so that small studies can yield more definitive answers. Finally, an understanding of patient risk profiles may enable clinicians to counsel patients more effectively and to set appropriate expectations for success. Patient age appears to be a strong risk factor for nonunion in some bones, a weak risk factor for nonunion in other bones, and perhaps not a significant risk factor for nonunion in certain bones. This observation suggests that there can be substantial bone-to-bone variation in nonunion risk. Age also may be a surrogate for the prevalence of risk factors that potentially increase with age, such as smoking, diabetes, obesity, or nonsteroidal anti-inflammatory drug (NSAID) use. Smoking has been replicated as a risk factor for nonunion only in retrospective studies involving the humerus and tibia. Smoking appears to have an important effect on nonunion, yet the incremental risk may be rather small, except in context with additional risk factors. Diabetes has been confirmed as a risk factor for nonunion only in retrospective studies involving the foot and ankle. Nonunion risk from diabetes alone may be small and the context of additional risk factors crucial; this could account for why it has been so difficult to predict nonunion in the individual patient. Prediction of fracture nonunion in the individual patient is a difficult problem. Fracture nonunion may be influenced by complex interactions between biological and surgical risk factors, and the nonunion rate varies from bone to bone. A randomized clinical trial may not appropriately control for all potential correlates and confounders and may require impractical sample sizes. A large claims-based study of real-world fracture-healing outcomes is needed to provide guidance for randomized clinical trials that can test risk factors more rigorously.

To determine the relationship between serum 25-hydroxyvitamin D [25(OH)D] levels and the likelihood of postoperative complications and fracture reoperation rate in orthopaedic trauma patients receiving vitamin D and calcium supplementation.Retrospective case series.Level I trauma center, Midwestern United States.All orthopaedic trauma patients-18 years or older-over a 20-month period were included with available initial and repeat 25(OH)D serum levels. In total, 201 patients met inclusion criteria.All patients received 1000 IU of vitamin D3 and 1500 mg of calcium daily. Vitamin D deficient and insufficient patients also received 50,000 IU of ergocalciferol (vitamin D2) weekly until 25(OH)D levels normalized or fractures healed.fracture complications and 25(OH)D levels.Fifteen patients experienced postoperative healing complications. There was no significant difference between initial (P = 0.92) or repeat (P = 0.91) 25(OH)D levels between patients with and without fracture healing complications. Twenty-eight patients required repeat orthopaedic surgery. There was no significant difference between initial (P = 0.62) or repeat (P = 0.18) 25(OH)D levels between patients who did or did not require repeat orthopaedic surgery. There was no significant difference between initial (P = 0.66) or repeat (P = 0.89) 25(OH)D levels between patients who did or did not require nonorthopaedic surgery.Serum 25(OH)D levels did not significantly affect the likelihood of fracture healing complications requiring surgery or any nonorthopaedic injury-related surgery.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Fractures involving the posterior aspect of the tibial plateau are challenging fractures to treat. Articular depression in tibial plateau fractures is usually addressed by elevation of the fragment(s), filling the residual defect with bone graft or bone substitute, and “raft” support of the articular fracture reduction with screws through a medially and/or laterally based plate. Posterior tibial plateau articular depression presents unique challenges for obtaining and maintaining fracture reduction. To obtain the goals of anatomic reduction and stable fixation, a thorough understanding of the fracture, specific approaches, reduction techniques, and stabilization strategies is needed. This article reviews the most current strategies for treating tibial plateau fracture patients with posterior articular depression.

Treatment of infected long bone fractures or nonunions requires stability for bony union, yet retained implants can lead to persistent infection. Antibiotic cement intramedullary nails, in addition to external fixation, are commonly used to deliver intramedullary antibiotics in infected long bone fractures and provide temporary stability. However, the retrieval of these nails can result in debonding of antibiotic cement, which can require significant time and effort to remove. A variety of methods, including intramedullary hooks, reverse curettes, flexible osteotomes, and stacked guide rods, are commonly used to remove cement fragments. When these methods fail to allow access to the entire length of the canal, the Reamer Irrigator Aspirator system (Synthes, Paoli, PA) serves as an effective method for removing retained intramedullary cement. The surgical technique is described, and three cases illustrate the successful use of the Reamer Irrigator Aspirator system for removal of an antibiotic cement intramedullary nail.

Periprosthetic fractures are fractures that occur in association with an orthopaedic implant, most often used for joint arthroplasty or fracture fixation. They are associated with significant morbidity and increased mortality in some cases. The incidence of periprosthetic fractures appears to be increasing as a result of increasing patient longevity, more demanding activity levels that persist into advanced age for some patients, and as a result of the increasing rate of revision arthroplasty which accompanies increasing patient longevity. Implant, surgeon, and patient factors all contribute to the risk of periprosthetic fracture. In this review, we intend to discuss current trends in periprosthetic fractures and risk factors associated with their development in the joint arthroplasty and fracture patient.

Pilon fractures associated with compartment syndrome are rare occurrences despite the relatively high-energy mechanisms that cause many pilon fractures. We report an unusual case of pilon fracture in an adult, which was complicated by development of compartment syndrome. It was successfully treated with four-compartment leg fasciotomy with good results. A high index of suspicion for compartment syndrome should be maintained in patients with intractable pain after pilon fracture.

Parathyroid hormone is a well-known regulator of calcium metabolism in the body. It binds to osteoblasts and assists in the regulation of bone turnover. Changes in parathyroid hormone levels have been documented in pathologic states such as osteoporosis, and fluxes are also noted during healing of fractures. Because fracture healing requires time and is sometimes unreliable, a search for fracture-healing adjuvants that accelerate the healing rate and improve reliability of healing is compelling. Parathyroid hormone, as a systemic mediator of calcium and bone metabolism, is a good candidate. Much research has been accomplished in animal models examining the role of parathyroid hormone in fracture healing. Although further research is required, especially in human fracture patients, early indicators are that parathyroid hormone may play a role in accelerating fracture healing in healthy patients and in reducing rates of fracture nonunion in compromised patients or tissue beds.

Background: The sustentaculum tali of the calcaneus is a vital load-bearing structure. Isolated sustentacular fractures are rare and may have implications for future hindfoot function. This retrospective cohort study describes sustentacular fracture patterns and characteristics, associated foot injuries, and a method of surgical treatment via a medial approach to the calcaneus. Materials and Methods: During a 7-year period, 19 surgically-treated sustentacular fractures without calcaneal posterior facet involvement were identified from a prospectively-collected database at a single Level 1 regional trauma center. Of these, 15 underwent open reduction and internal fixation utilizing a medial approach to the calcaneus. Patient charts, plain radiographs, and CT scans were reviewed for injury characteristics/morphology and associated musculoskeletal injuries. Results: Fourteen patients had associated ipsilateral foot/ankle injuries, and nine had other musculoskeletal injuries. Seven patients had intra-articular middle facet involvement, and seven had subtalar joint subluxation or dislocation. The medial approach to the calcaneus involves distal retraction of the neurovascular bundle and toe flexors. This allowed for an accurate indirect articular reduction using the extraarticular medial calcaneal cortex, as well as reduction of any associated subluxations. No complications were related to the surgical approach. Reduction was maintained through fracture healing. Conclusion: Fractures of the sustentaculum tali are rare injuries associated with high energy mechanisms, and associated ipsilateral foot injuries are common. Open reduction and internal fixation of these fractures was reliable and possible through a medial approach involving distal retraction of the digital flexors and neurovascular bundle, allowing for an anatomical extraarticular cortical reduction.Level of Evidence: IV, Retrospective Case Series

Item does not contain fulltext BACKGROUND: The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) has been extensively evaluated in groups of patients with osteoarthritis, yet not in patients with a femoral neck fracture. This study aimed to determine the reliability, construct validity, and responsiveness of the WOMAC compared with the Short Form-12 (SF-12) and the EuroQol 5D (EQ-5D) questionnaires for the assessment of elderly patients with a femoral neck fracture. METHODS: Reliability was tested by assessing the Cronbach alpha. Construct validity was determined with the Pearson correlation coefficient. Change scores were calculated from ten weeks to twelve months of follow-up. Standardized response means and floor and ceiling effects were determined. Analyses were performed to compare the results for patients less than eighty years old with those for patients eighty years of age or older. RESULTS: The mean WOMAC total score was 89 points before the fracture in the younger patients and increased from 70 points at ten weeks to 81 points at two years postoperatively. In the older age group, these scores were 86, 75, and 78 points. The mean WOMAC pain scores before the fracture and at ten weeks and two years postoperatively were 92, 76, and 87 points, respectively, in the younger age group and 92, 84, and 93 points in the older age group. Function scores were 89, 68, and 79 points for the younger age group and 84, 71, and 73 points for the older age group. The Cronbach alpha for pain, stiffness, function, and the total scale ranged from 0.83 to 0.98 for the younger age group and from 0.79 to 0.97 for the older age group. Construct validity was good, with 82% and 79% of predefined hypotheses confirmed in the younger and older age groups, respectively. Responsiveness was moderate. No floor effects were found. Moderate to large ceiling effects were found for pain and stiffness scales at ten weeks and twelve months in younger patients (18% to 36%) and in the older age group (38% to 53%). CONCLUSIONS: The WOMAC showed good reliability, construct validity, and responsiveness in both age groups of elderly patients with a femoral neck fracture who had been physically and mentally fit before the fracture. The instrument is suitable for use in future clinical studies in these populations. CLINICAL RELEVANCE: The results are based on two clinical trials. The questionnaires used concern pure, clinically relevant issues (ability to walk, climb stairs, etc.). Moreover, the results can be used for future research comparing clinical outcomes (or treatments) for populations with a femoral neck fracture.

Background Patient age is one of many potential risk factors for fracture nonunion. Our hypothesis is that older patients (≥60) with fracture risk factors treated with low-intensity pulsed ultrasound (LIPUS) have similar heal rate (HR) to the population as a whole. We evaluate the impact of age in conjunction with other risk factors on HR in LIPUS-treated patients with fresh fracture (≤90 days old). Methods The Exogen Bone Healing System is a LIPUS device approved in 1994 to accelerate healing of fresh fracture. After approval, the FDA required a Post-Market Registry to assess performance. Patient data collected from October 1994 until October 1998 were individually reviewed and validated by a registered nurse. Four distinct data elements were required to report a patient: date fracture occurred; date treatment began; date treatment ended; and a dichotomous outcome of healed v. failed, by clinical and radiological criteria. Data were used to calculate two derived variables; days to treatment (DTT) and days on treatment (DOT). Every validated fresh fracture patient with DTT, DOT, and outcome is reported. Results The validated registry had 5,765 patients with fresh fracture; 73% (N = 4,190) are reported, while 13% of patients were lost to follow-up, 11% withdrew or were non-compliant, and 3% died or are missing outcome. Among treatment-compliant patients, HR was 96.2%. Logistic estimates of the odds ratio for healing are equivalent for patients age 30 to 79 years and all age cohorts had a HR > 94%. Open fracture, current smoking, diabetes, vascular insufficiency, osteoporosis, cancer, rheumatoid arthritis, and prescription NSAIDs all reduced HR, but older patients (≥60) had similar HRs to the population as a whole. DTT was significantly shorter for patients who healed (p

BackgroundEstablished fracture nonunions rarely heal without secondary intervention. Revision surgery is the most common intervention, though non-surgical options for nonunion would be useful if they could overcome nonunion risk factors. Our hypothesis is that low-intensity pulsed ultrasound (LIPUS) can enhance heal rate (HR) in fractures that remain nonunion after one year, relative to the expected HR in the absence of treatment, which is expected to be negligible.MethodsWe collated outcomes from a prospective patient registry required by the U.S. Food & Drug Administration. Patient data were collected over a 4-year period beginning in 1994 and were individually reviewed and validated by a registered nurse. Patients were only included if they had four data points available: date when fracture occurred; date when LIPUS treatment began; date when LIPUS treatment ended; and a dichotomous outcome of healed vs. failed, assessed by clinical and radiological criteria. Data were used to calculate two derived variables: days to treatment (DTT) with LIPUS, and days on treatment (DOT) with LIPUS. Every validated chronic nonunion patient (DTT>365 days) with complete data is reported.ResultsHeal rate for chronic nonunion patients (N=767) treated with LIPUS was 86.2%. Heal rate was 82.7% among 98 patients with chronic nonunion ≥5 years duration, and 12 patients healed after chronic nonunion >10 years (HR=63.2%). There was more patient loss to follow-up, non-compliance, and withdrawal, comparing chronic nonunion patients to all other patients (p10 years. LIPUS resulted in successful healing in the majority of nonunions without further surgical intervention.

External fixation for definitive therapy of closed diaphyseal femur and tibia fractures is the preferred method of treatment only in the pediatric population. In adult injuries, in particular open battle wounds, the timing of conversion of an external fixator to an intramedullary nail is determined by the condition of the soft tissues and the overall stability of the patient. In the tibia, conversion to an intramedullary nail is accomplished as expeditiously as possible. Early (< 2 weeks) conversion to an intramedullary implant may be accomplished safely. Increased infection rates have been documented when conversion is done after 2 weeks of external fixation. In the femur, conversion from external fixation to nailing is done as the patient's overall physical condition and soft tissues allow. Acute conversion to an intramedullary device in a single procedure is preferred in patients without evidence of pin-tract infection. Staged conversion to an intramedullary nail often requires a prolonged period of bed rest with skeletal traction to maintain fracture stability and patient comfort, with the attendant risks of pneumonia, decubiti, and thromboembolic events. Treatment of closed femoral and tibial diaphyseal fractures with external fixation, either definitively or as a bridge to intramedullary nailing, is a viable option in the patient with gross physiologic instability or an ipsilateral dysvascular limb. The decision to use definitive external fixation versus conversion to an intramedullary device should be made on a case-by-case basis. Additional prospective clinical studies are warranted to further delineate risks and benefits of these treatment modalities.

Background: The clinical presentation of a labral tear of the acetabulum may be variable, and the diagnosis is often delayed. We sought to define the clinical characteristics associated with symptomatic acetabular labral tears by reviewing a group of patients who had an arthroscopically confirmed diagnosis. Methods: We retrospectively reviewed the records for sixty-six consecutive patients (sixty-six hips) who had a documented labral tear that had been confirmed with hip arthroscopy. We had prospectively recorded demographic factors, symptoms, physical examination findings, previous treatments, functional limitations, the manner of onset, the duration of symptoms until the diagnosis of the labral tear, other diagnoses offered by health-care providers, and other surgical procedures that these patients had undergone. Radiographic abnormalities and magnetic resonance arthrography findings were also recorded. Results: The study group included forty-seven female patients (71%) and nineteen male patients (29%) with a mean age of thirty-eight years. The initial presentation was insidious in forty patients, was associated with a low-energy acute injury in twenty, and was associated with major trauma in six. Moderate to severe pain was reported by fifty-seven patients (86%), with groin pain predominating (sixty-one patients; 92%). Sixty patients (91%) had activity-related pain (p < 0.0001), and forty-seven patients (71%) had night pain (p = 0.0006). On examination, twenty-six patients (39%) had a limp, twenty-five (38%) had a positive Trendelenburg sign, and sixty-three (95%) had a positive impingement sign. The mean time from the onset of symptoms to the diagnosis of a labral tear was twenty-one months. A mean of 3.3 health-care providers had been seen by the patients prior to the definitive diagnosis. Surgery on another anatomic site had been recommended for eleven patients (17%), and four had undergone an unsuccessful operative procedure prior to the diagnosis of the labral tear. At an average of 16.4 months after hip arthroscopy, fifty-nine patients (89%) reported clinical improvement in comparison with the preoperative status. Conclusions: The clinical presentation of a patient who has a labral tear may vary, and the correct diagnosis may not be considered initially. In young, active patients with a predominant complaint of groin pain with or without a history of trauma, the diagnosis of a labral tear should be suspected and investigated as radiographs and the history may be nonspecific for this diagnosis. Level of Evidence: Diagnostic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Background: Endoscopic carpal tunnel release is gaining increasing acceptance relative to the standard open carpal tunnel release for the treatment of carpal tunnel syndrome. Concerns about endoscopic carpal tunnel release include effectiveness of therapy and complication rates. This study attempted to evaluate outcomes of endoscopic carpal tunnel release in a large patient cohort. Methods: Four hundred eighty-six patients (753 hands) with carpal tunnel syndrome who underwent endoscopic carpal tunnel release by a single surgeon were reviewed retrospectively. Data included demographics, subjective complaints, prior interventions, preoperative examination findings, and postoperative follow-up. All follow-up data were obtained from a single, independent, occupational therapy clinic. Results: Median patient age was 48 years. Three hundred seventy-seven patients were gainfully employed at presentation, and 206 filed a worker's compensation claim. Median symptom duration was 2 years. Nonoperative therapy was ineffective in 151 patients. Preoperative nerve conduction studies were consistent with carpal tunnel syndrome in 472 patients (97 percent); all patients had either physical examination findings or nerve conduction studies consistent with carpal tunnel syndrome. Four hundred eighty-six patients (100 percent) obtained symptom relief. Complications included one transient median nerve neurapraxia, six complaints of residual pain, and one complaint of hypersensitivity. Worker's compensation patients and non–worker's compensation patients returned to work full-duty at similar times postoperatively. Ninety percent of employed patients returned to their original occupation. Conclusions: The authors' data indicate that an endoscopic approach for the treatment of carpal tunnel syndrome is safe and effective. Patients demonstrated a high return-to-work rate and an extremely low complication rate. The data challenge the belief that endoscopic carpal tunnel release results in higher complication rates.

Introduction The use of low intensity pulsed ultrasound (LIPUS) in the treatment of nonunions is still controversial. The present study is concerned with whether this procedure has a clinical use and which cofactors influence its therapeutic results. Methods In this prospective, single institution, observational study, data from October 2010 to October 2013 from 61 nonunions in 60 patients treated with EXOGEN® LIPUS therapy were analysed. The average age was 45.4 ± 9.81 (18–63) years. Treatment was primarily done on long bones of the lower extremity (75.4 %). All 61 nonunions were examined after treatment, and the rate of healing as well as functional and subjective results were evaluated. Based on clinical and radiological findings, patients were divided into two groups: G1—successful treatment; and G2—unsuccessful treatment. Groups were compared to one another to identify possible factors influencing treatment. Results Twenty (32.8 %) patients showed bone consolidation with an average time of healing of 5.3 (2–7) months. In patients without successful treatment, who underwent revision surgery instead, full weight bearing took on average 3.7 months longer, and they were able to return to work 6.8 months later. Most of the treated patients (70.5 %) reported no improvement in pain. In G2, 12 (29.3 %) patients suffered in their previous history from osteitis; in G1 there were only two patients (10 %) (p = 0.012). There were further significant differences in the age of the fracture, the type of osteosynthesis, the gap size, as well as the NUSS score. Conclusion Despite patients being chosen strictly according to EXOGEN® indications, only a small number of patients with nonunions who underwent LIPUS therapy experienced successful treatment (32.8 %). Overall, its use resulted in a clear delay in the time of treatment, so that according to our results, the use of LIPUS should be seen critically in long bone nonunions and use should be made on a case-by-case basis.

STUDY DESIGN A retrospective clinical and radiographic analysis of long adult deformity fusions terminating at L5. OBJECTIVES To define the results of thoracolumbar fusions to L5 in adult deformity patients with critical evaluation for potential subsequent L5-S1 disc degeneration and L5 implant loosening. SUMMARY OF BACKGROUND DATA Few studies have reported the results of long adult fusions to L5 and the potential for subsequent advanced L5-S1 disc degeneration is unknown. MATERIALS AND METHODS Thirty-four consecutive patients fused from the thoracic spine to L5 at a single institution were evaluated at a mean follow-up of 5.6 years (2.1-14.3 years). SRS-24 functional outcome questionnaire results were obtained for all patients at most recent follow-up. RESULTS By latest follow-up, subsequent advanced L5-S1 disc degeneration (SAD) developed in 19 of 31 patients (61%) assessed as having "healthy" discs before surgery. SAD was associated with a forward shift in sagittal balance (P = 0.02) and need for revision surgery (P = 0.02). Risk factors for the development of SAD were preoperative positive sagittal balance (P = 0.01), younger age (P = 0.03), and the presence of even mild radiographic degeneration before surgery (P = 0.004). Loss of L5 implant fixation occurred in six patients (18%) and was associated with deep seating of L5 within the pelvis (P = 0.0001). Inferior SRS-24 outcome measures were associated with preoperative advanced L5-S1 disc degeneration and the development of postoperative sagittal imbalance. CONCLUSIONS Subsequent L5-S1 DDD developed in 61% of patients after long adult fusions to L5 and was associated with a significant loss of sagittal alignment and an increased likelihood for or definite need for another operation. Loss of L5 implant fixation is not uncommon, especially in patients with a deep-seated L5 vertebra.

Femoral neck fractures in young adults are difficult to treat. There are substantial gaps in our knowledge regarding treatment and prevention of young adult femoral neck fractures. Avoiding malunion or nonunion of these fractures after fixation remains a challenge. Currently available fixation techniques may allow for healing to occur, but in a shortened position, with negative consequences on gait mechanics and physical function. Osteonecrosis remains a problem, affecting up to half of patients who sustain femoral neck fractures. Achieving reliable healing may require a reconsideration of fracture fixation implants as well as biological methods to address metabolic, endocrine, and/or genetic abnormalities that may be present in the young adult femoral neck fracture patient. Also, prevention of low-energy femoral neck fractures (e.g. stress fracture) remains an area ripe for investigation.

This article considers the role of knowledge translation as an important aspect of the current United Nations campaign called the Decade of Action for Road Traffic Safety (2011-2020). There are 5 tiers to this safety program: improving health care services, improving management of road safety, improving road network safety, improving vehicular safety, and improving road safety legislation. The authors review published, practical research in each of these 5 areas, focusing on identifying areas that need additional research. They note that much research focuses only on whether crashes result in survivors or fatalities, rather than characterizing crash victims who may experience ongoing disabilities as a result of a crash. This is true especially when categorizing orthopedic injuries in patients who survive crashes. The authors call for the development of a method of capturing different orthopedic injuries into an appropriate database that can then be correlated with disability in survivors of road traffic crashes. Other topics covered include the need for changes in basic transportation infrastructure, including that designed for use by bicyclists and pedestrians; the role of redesigned vehicle bumpers for pedestrian and bicyclist safety; the role of 2-wheeled motorized vehicles, particularly in the developing world; returning to driving after an orthopedic injury to the arms, legs, and/or pelvis; and legislation designed to improve vehicular safety.

Promiscuous coupling between G protein-coupled receptors and multiple species of heterotrimeric G proteins provides a potential mechanism for expanding the diversity of G protein-coupled receptor signaling. We have examined the mechanism and functional consequences of dual Gs/Gi protein coupling of the beta3-adrenergic receptor (beta3AR) in 3T3-F442A adipocytes. The beta3AR selective agonist disodium (R, R)-5-[2[[2-(3-chlorophenyl)-2-hydroxyethyl]-amino]propyl]-1, 3-benzodioxole-2,2-dicarboxylate (CL316,243) stimulated a dose-dependent increase in cAMP production in adipocyte plasma membrane preparations, and pretreatment of cells with pertussis toxin resulted in a further 2-fold increase in cAMP production by CL316,243. CL316,243 (5 microM) stimulated the incorporation of 8-azido-[32P]GTP into Galphas (1.57 +/- 0.12; n = 3) and Galphai (1. 68 +/- 0.13; n = 4) in adipocyte plasma membranes, directly demonstrating that beta3AR stimulation results in Gi-GTP exchange. The beta3AR-stimulated increase in 8-azido-[32P]GTP labeling of Galphai was equivalent to that obtained with the A1-adenosine receptor agonist N6-cyclopentyladenosine (1.56 +/- 0.07; n = 4), whereas inclusion of unlabeled GTP (100 microM) eliminated all binding. Stimulation of the beta3AR in 3T3-F442A adipocytes led to a 2-3-fold activation of mitogen-activated protein (MAP) kinase, as measured by extracellular signal-regulated kinase-1 and -2 (ERK1/2) phosphorylation. Pretreatment of cells with pertussis toxin (PTX) eliminated MAP kinase activation by beta3AR, demonstrating that this response required receptor coupling to Gi. Expression of the human beta3AR in HEK-293 cells reconstituted the PTX-sensitive stimulation of MAP kinase, demonstrating that this phenomenon is not exclusive to adipocytes or to the rodent beta3AR. ERK1/2 activation by the beta3AR was insensitive to the cAMP-dependent protein kinase inhibitor H-89 but was abolished by genistein and AG1478. These data indicate that constitutive beta3AR coupling to Gi proteins serves both to restrain Gs-mediated activation of adenylyl cyclase and to initiate additional signal transduction pathways, including the ERK1/2 MAP kinase cascade.

Hunters who fall from deer stands can sustain a variety of injuries. A retrospective review was conducted at a single institution to gauge the experience in treating patients injured in falls from deer stands from 2002 to 2008. Medical records were analyzed for patient demographics, tree stand characteristics, and injury details. Patients were contacted to complete a SF-12 health survey to assess their functional outcome following their injuries. Of the 30 patients who sustained a fracture, an average of 2.08 fractures were sustained per patient. Sixteen patients sustained a spinal column fracture, and four of these sustained a spinal cord injury. Twenty-one patients underwent at least one surgical procedure by the trauma surgery (two), neurosurgery (four), or orthopaedic surgery (15) teams. The importance of understanding deer stand instructions should be emphasized during hunting education classes, and all hunters should follow safe hunting recommendations pertaining to firearms and tree stands. Language: en

Early surgical intervention is thought to reduce in-hospital morbidity and mortality as well as short-term mortality rates for elderly patients with hip fractures. However, hip fractures are also thought to be a symptom of progressive decline in elderly patients with multiple medical comorbidities. A measured approach to medical optimization, which may preclude rapid surgical intervention, is often required to improve the patient's ability to resume a prefracture standard of living. Of late, new models of geriatric hip-fracture care have emerged, most of which entail early involvement of geriatricians and interdisciplinary care pathways, while continuing to focus on rapid surgical treatment.

Several factors are conspiring to cause a dramatic increase in the incidence of periprosthetic fractures. First, the incidence of arthroplasty is increasing as the population ages. Second, arthroplasty is being performed in younger, more active patients, who live longer after their arthroplasty and are more likely to have subsequent trauma to their previously operated limb. Third, following lower extremity surgery, disuse osteopenia of the limb often occurs, increasing the risk of subsequent fracture in that same limb. This increased risk of later fracture is further aggravated by the implant placed at the previous surgery, which often functions as a mechanical stress riser. Careful attention to detail during knee arthroplasty or during fracture repair in which fixation is placed close to the knee is beneficial for minimizing the risk of subsequent periprosthetic fracture. Intraoperative vigilance, judicious use of force when inserting implants, and meticulous technical execution of the procedure may all reduce fracture complications postoperatively. This article reviews the prevalence of periprosthetic fractures about knee arthroplasties and fracture fixation constructs, and also provides a description of common recommendations intended to reduce the risk of periprosthetic fracture.

Purpose To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. Methods We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." Results According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most important factors when evidence shows no difference between 2 surgeries were "fewer complications," "quicker recovery," "burns fewer bridges," "works in my hands" and "familiarity with the procedure." Europeans rated "works in my hands" and "cheapest/most resourceful" of significantly greater importance and "what others are doing," "highest reimbursement," and "shorter procedure" of significantly lower importance than surgeons in the United States. Observers with fewer than 10 years in independent practice rated "what my mentor taught me," "what others are doing" and "highest reimbursement" of significantly lower importance compared to observers with 10 or more years in independent practice. Conclusions Surgeons deciding between 2 treatment options, when the evidence is inconclusive, fall back to factors that relate to their perspective and reflect their culture and circumstances, more so than factors related to the patient's perspective, although this may be different for younger surgeons. Clinical relevance Hand surgeons might benefit from consensus fallback preferences when evidence is inconclusive. It is possible that falling back to personal comfort makes us vulnerable to unhelpful commercial and societal influences.