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© 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.

Background Intimate partner violence (IPV)—physical, sexual, psychologic, or financial abuse between intimate partners—is the most common cause of nonfatal injury to women in North America. As many IPV-related injuries are musculoskeletal, orthopaedic surgeons are well positioned to identify and assist these patients. However, data are lacking regarding surgeons’ knowledge of the prevalence of IPV in orthopaedic practices, surgeons’ screening and management methods, and surgeons’ perceptions about IPV.

The objective of this 3-year retrospective, controlled, cohort study is to characterize an interdisciplinary method of managing geriatric patients with hip fracture. All patients aged 65 years or older admitted to a single academic level I trauma center during a 3-year period with an isolated hip fracture were included as participants for this study. Thirty-one geriatric patients with hip fracture were treated with historical methods of care (cohort 1). The comparison group of 115 similar patients was treated under a newly developed, institutional comanagement hip fracture protocol (cohort 2). There were no differences in age, sex distribution, or comorbidity distribution between the 2 cohorts. Patients requiring intensive care unit (ICU) admission decreased significantly from 48% in cohort 1 to 23% in cohort 2 ( P = .0091). Length of ICU stay for patients requiring ICU admission also decreased significantly, from a mean of 8.1 days in cohort 1 to 1.8 days in cohort 2 ( P = .024). Total hospital stay decreased significantly, from a mean of 9.9 days in cohort 1 to 7.1 days in cohort 2 ( P = .021). Although no decrease in in-hospital mortality rates was noted from cohort 1 to cohort 2, a trend toward decreased 1-year mortality rates was seen after implementation of the hip fracture protocol. Hospital charges decreased significantly, from US$52 323 per patient in cohort 1 to US$38 586 in cohort 2 ( P = .0183). Implementation of a comanagement protocol for care of geriatric patients with hip fracture, consisting of admission to a geriatric primary care service, standardized perioperative assessment regimens, expeditious surgical treatment, and continued primary geriatric care postoperatively, resulted in reductions in lengths of stay, ICU admissions, and hospital costs per patient. On an annualized basis, this represented a savings of over US$700 000 for our institution.

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.

Background Pilon fractures continue to be a treatment challenge. The purpose of this study was to examine our rate of early (up to 6 weeks) complications associated with using the anterolateral approach to the distal tibia. Methods Thirty-six patients treated between September, 2005, and July, 2007, at a level I trauma center were reviewed. Patients were treated by two fellowship-trained orthopaedic trauma surgeons. Patients followed the standard staged protocol used for pilon fractures with early external fixation after injury and delayed definitive operative fixation through an anterolateral approach. Patients were examined clinically at 2–3 weeks and then 6 weeks for complications associated with the surgical approach. Results All fractures were AO/OTA type C fractures (72% C3, 19% C2, and 8% C1). Nine of the 36 patients (24.7%) had wound complications related to the anterolateral incision. Six patients (16.7%) had minor complications, and three (8%) had major complications. The three major complications were deep wound infections; the six minor complications were treated successfully with oral antibiotics and local wound care. Conclusions Open reduction and internal fixation of pilon fractures using an anterolateral approach provided an extensile approach to the distal tibia and ankle with a relatively low incidence of major early wound complications in a series of patients with highly complex pilon fractures.

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.

A technical benefit of the reamer-irrigator-aspirator (RIA) system (Synthes, Paoli, PA) is the ability to harvest large volumes (40-90 cm3) of autogenous bone graft. Early evaluations of this technique have reported few problems, all of which were attributed to technical error. This case series reviews 6 RIA-associated complications including 4 fractures and their contributing risk factors. Cases were collected from 4 independent orthopaedic centers, and all patients underwent RIA bone graft harvesting in a lower extremity long bone injuries. In this population, 2 patients experienced acute RIA-associated events, necessitating an additional procedure or altered postoperative rehabilitation, whereas 4 patients fractured through their donor site in the early postoperative period. This series suggests that surgeons should (1) preoperatively assess cortical diameters at long bone harvest sites, (2) carefully monitor intraoperative reaming, and (3) avoid RIA bone graft harvesting in patients with a history of osteoporosis or osteopenia unless postharvest intramedullary stabilization is considered.

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.

Importance Failure of bone fracture healing occurs in 5% to 10% of all patients. Nonunion risk is associated with the severity of injury and with the surgical treatment technique, yet progression to nonunion is not fully explained by these risk factors. Objective To test a hypothesis that fracture characteristics and patient-related risk factors assessable by the clinician at patient presentation can indicate the probability of fracture nonunion. Design, Setting, and Participants An inception cohort study in a large payer database of patients with fracture in the United States was conducted using patient-level health claims for medical and drug expenses compiled for approximately 90.1 million patients in calendar year 2011. The final database collated demographic descriptors, treatment procedures as per Current Procedural Terminology codes; comorbidities as per International Classification of Diseases, Ninth Revision codes; and drug prescriptions as per National Drug Code Directory codes. Logistic regression was used to calculate odds ratios (ORs) for variables associated with nonunion. Data analysis was performed from January 1, 2011, to December 31, 2012, Exposures Continuous enrollment in the database was required for 12 months after fracture to allow sufficient time to capture a nonunion diagnosis. Results The final analysis of 309 330 fractures in 18 bones included 178 952 women (57.9%); mean (SD) age was 44.48 (13.68) years. The nonunion rate was 4.9%. Elevated nonunion risk was associated with severe fracture (eg, open fracture, multiple fractures), high body mass index, smoking, and alcoholism. Women experienced more fractures, but men were more prone to nonunion. The nonunion rate also varied with fracture location: scaphoid, tibia plus fibula, and femur were most likely to be nonunion. The ORs for nonunion fractures were significantly increased for risk factors, including number of fractures (OR, 2.65; 95% CI, 2.34-2.99), use of nonsteroidal anti-inflammatory drugs plus opioids (OR, 1.84; 95% CI, 1.73-1.95), operative treatment (OR, 1.78; 95% CI, 1.69-1.86), open fracture (OR, 1.66; 95% CI, 1.55-1.77), anticoagulant use (OR, 1.58; 95% CI, 1.51-1.66), osteoarthritis with rheumatoid arthritis (OR, 1.58; 95% CI, 1.38-1.82), anticonvulsant use with benzodiazepines (OR, 1.49; 95% CI, 1.36-1.62), opioid use (OR, 1.43; 95% CI, 1.34-1.52), diabetes (OR, 1.40; 95% CI, 1.21-1.61), high-energy injury (OR, 1.38; 95% CI, 1.27-1.49), anticonvulsant use (OR, 1.37; 95% CI, 1.31-1.43), osteoporosis (OR, 1.24; 95% CI, 1.14-1.34), male gender (OR, 1.21; 95% CI, 1.16-1.25), insulin use (OR, 1.21; 95% CI, 1.10-1.31), smoking (OR, 1.20; 95% CI, 1.14-1.26), benzodiazepine use (OR, 1.20; 95% CI, 1.10-1.31), obesity (OR, 1.19; 95% CI, 1.12-1.25), antibiotic use (OR, 1.17; 95% CI, 1.13-1.21), osteoporosis medication use (OR, 1.17; 95% CI, 1.08-1.26), vitamin D deficiency (OR, 1.14; 95% CI, 1.05-1.22), diuretic use (OR, 1.13; 95% CI, 1.07-1.18), and renal insufficiency (OR, 1.11; 95% CI, 1.04-1.17) (multivariate P Conclusions and Relevance The probability of fracture nonunion can be based on patient-specific risk factors at presentation. Risk of nonunion is a function of fracture severity, fracture location, disease comorbidity, and medication use.

Purpose: To investigate the level of expression, activation state, and functional significance of extracellular signal regulated kinase (ERK) in prostate cancer.Materials and Methods: Human prostate tissue samples (n = 22) were obtained from patients undergoing radical prostatectomy for localized adenocarcinoma of the prostate (n = 16, age range 44 to 72 years) or normal prostate specimens (n = 6, age ranges 19 to 47 years) obtained from rapid autopsy. Immunoblots, in vitro kinase assays, and immunohistochemistry were used to determine the expression and activation state of ERK in human prostate cancer.Results: Immunoblot and in vitro kinase assays demonstrated a 15-fold increase in ERK activation in prostate cancer specimens compared with normal human prostate tissue; however, ERK expression levels were only 1.3-fold higher in cancer. Immunohistochemical analysis demonstrated similar expression of ERK in cancer and normal tissues; however, phosphorylated ERK demonstrated greater intensity in the ...

G protein-coupled receptors (GPCRs) initiate Ras-dependent activation of the Erk 1/2 mitogen-activated protein kinase cascade by stimulating recruitment of Ras guanine nucleotide exchange factors to the plasma membrane. Both integrin-based focal adhesion complexes and receptor tyrosine kinases have been proposed as scaffolds upon which the GPCR-induced Ras activation complex may assemble. Using specific inhibitors of focal adhesion complex assembly and receptor tyrosine kinase activation, we have determined the relative contribution of each to activation of the Erk 1/2 cascade following stimulation of endogenous GPCRs in three different cell types. The tetrapeptide RGDS, which inhibits integrin dimerization, and cytochalasin D, which depolymerizes the actin cytoskeleton, disrupt the assembly of focal adhesions. In PC12 rat pheochromocytoma cells, both agents block lysophosphatidic acid (LPA)- and bradykinin-stimulated Erk 1/2 phosphorylation, suggesting that intact focal adhesion complexes are required for GPCR-induced mitogen-activated protein kinase activation in these cells. In Rat 1 fibroblasts, Erk 1/2 activation via LPA and thrombin receptors is completely insensitive to both agents. Conversely, the epidermal growth factor receptor-specific tyrphostin AG1478 inhibits GPCR-mediated Erk 1/2 activation in Rat 1 cells but has no effect in PC12 cells. In HEK-293 human embryonic kidney cells, LPA and thrombin receptor-mediated Erk 1/2 activation is partially sensitive to both the RGDS peptide and tyrphostin AG1478, suggesting that both focal adhesion and receptor tyrosine kinase scaffolds are employed in these cells. The dependence of GPCR-mediated Erk 1/2 activation on intact focal adhesions correlates with expression of the calcium-regulated focal adhesion kinase, Pyk2. In all three cell types, GPCR-stimulated Erk 1/2 activation is significantly inhibited by the Src kinase inhibitors, herbimycin A and 4-amino-5-(4-methylphenyl)-7-(t-butyl)pyrazolo-d-3,4-pyrimidine (PP1), suggesting that Src family nonreceptor tyrosine kinases represent a point of convergence for signals originating from either scaffold.

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.

The Ras-dependent activation of Erk kinases by G protein-coupled receptors (GPCRs) is thought to involve tyrosine phosphorylation of docking proteins that serve as scaffolds for the plasma membrane recruitment of Ras guanine nucleotide exchange factors, such as the Grb2-mSos complex. We have investigated the role of two GPCR-regulated tyrosine phosphoproteins, p125FAK (FAK) and Shc, in the Ras-dependent activation of Erk kinases by endogenously expressed GPCRs in Rat 1a fibroblasts. Several lines of evidence suggest that tyrosine phosphorylation of FAK and Shc are independently regulated. The GPCRs for lysophosphatidic acid (LPA), thrombin, and bombesin mediate equivalent increases in FAK tyrosine phosphorylation and FAK-Grb2 association. In contrast, only LPA and thrombin receptors significantly stimulate Shc tyrosine phosphorylation and Shc-Grb2 complex formation. Tyrosine phosphorylation of FAK is pertussis toxin-insensitive, can be mimicked by calcium ionophore, and is inhibited by treatment with cytochalasin D, which depolymerizes the actin cytoskeleton. In contrast, tyrosine phosphorylation of Shc is inhibited by pertussis toxin treatment, is not induced by calcium ionophore, and is insensitive to cytochalasin D. In each case, the rapid stimulation of Erk 1/2 correlates with tyrosine phosphorylation of Shc but not of FAK. The dissociation of FAK-Grb2 complex formation from receptor-mediated activation of Erk 1/2 indicates that recruitment of Grb2-mSos to the plasma membrane is not sufficient to mediate rapid Erk activation. Using four mechanistically distinct inhibitors of clathrin-mediated endocytosis, concanavalin A, hypertonic medium, depletion of intracellular potassium, and monodansylcadaverine, we find that GPCR-mediated Erk 1/2 activation is also endocytosis-dependent. Thus, we propose that an additional step involving vesicle-mediated endocytosis is required for the rapid, Ras-dependent activation of Erk kinases in fibroblasts.

Many receptors that couple to heterotrimeric guanine-nucleotide binding proteins (G proteins) have been shown to mediate rapid activation of the mitogen-activated protein kinases Erk1 and Erk2. In different cell types, the signaling pathways employed appear to be a function of the available repertoire of receptors, G proteins, and effectors. In HEK-293 cells, stimulation of either alpha1B- or alpha2A-adrenergic receptors (ARs) leads to rapid 5-10-fold increases in Erk1/2 phosphorylation. Phosphorylation of Erk1/2 in response to stimulation of the alpha2A-AR is effectively attenuated by pretreatment with pertussis toxin or by coexpression of a Gbetagamma subunit complex sequestrant peptide (betaARK1ct) and dominant-negative mutants of Ras (N17-Ras), mSOS1 (SOS-Pro), and Raf (DeltaN-Raf). Erk1/2 phosphorylation in response to alpha1B-AR stimulation is also attenuated by coexpression of N17-Ras, SOS-Pro, or DeltaN-Raf, but not by coexpression of betaARK1ct or by pretreatment with pertussis toxin. The alpha1B- and alpha2A-AR signals are both blocked by phospholipase C inhibition, intracellular Ca2+ chelation, and inhibitors of protein-tyrosine kinases. Overexpression of a dominant-negative mutant of c-Src or of the negative regulator of c-Src function, Csk, results in attenuation of the alpha1B-AR- and alpha2A-AR-mediated Erk1/2 signals. Chemical inhibitors of calmodulin, but not of PKC, and overexpression of a dominant-negative mutant of the protein-tyrosine kinase Pyk2 also attenuate mitogen-activated protein kinase phosphorylation after both alpha1B- and alpha2A-AR stimulation. Erk1/2 activation, then, proceeds via a common Ras-, calcium-, and tyrosine kinase-dependent pathway for both Gi- and Gq/11-coupled receptors. These results indicate that in HEK-293 cells, the Gbetagamma subunit-mediated alpha2A-AR- and the Galphaq/11-mediated alpha1B-AR-coupled Erk1/2 activation pathways converge at the level of phospholipase C. These data suggest that calcium-calmodulin plays a central role in the calcium-dependent regulation of tyrosine phosphorylation by G protein-coupled receptors in some systems.

In many cells, stimulation of mitogen-activated protein kinases by both receptor tyrosine kinases and receptors that couple to pertussis toxin-sensitive heterotrimeric G proteins proceed via convergent signaling pathways. Both signals are sensitive to inhibitors of tyrosine protein kinases and require Ras activation via phosphotyrosine-dependent recruitment of Ras guanine nucleotide exchange factors. Receptor tyrosine kinase stimulation mediates ligand-induced receptor autophosphorylation, which creates the initial binding sites for SH2 domain-containing docking proteins. However, the mechanism whereby G protein-coupled receptors mediate the phosphotyrosine-dependent assembly of a mitogenic signaling complex is poorly understood. We have studied the role of Src family nonreceptor tyrosine kinases in G protein-coupled receptor-mediated tyrosine phosphorylation in a transiently transfected COS-7 cell system. Stimulation of Gi-coupled lysophosphatidic acid and alpha2A adrenergic receptors or overexpression of Gbeta1gamma2 subunits leads to tyrosine phosphorylation of the Shc adapter protein, which then associates with tyrosine phosphoproteins of approximately 130 and 180 kDa, as well as Grb2. The 180-kDa Shc-associated tyrosine phosphoprotein band contains both epidermal growth factor (EGF) receptor and p185(neu). 3-5-fold increases in EGF receptor but not p185(neu) tyrosine phosphorylation occur following Gi-coupled receptor stimulation. Inhibition of endogenous Src family kinase activity by cellular expression of a dominant negative kinase-inactive mutant of c-Src inhibits Gbeta1gamma2 subunit-mediated and Gi-coupled receptor-mediated phosphorylation of both EGF receptor and Shc. Expression of Csk, which inactivates Src family kinases by phosphorylating the regulatory carboxyl-terminal tyrosine residue, has the same effect. The Gi-coupled receptor-mediated increase in EGF receptor phosphorylation does not reflect increased EGF receptor autophosphorylation, assayed using an autophosphorylation-specific EGF receptor monoclonal antibody. Lysophosphatidic acid stimulates binding of EGF receptor to a GST fusion protein containing the c-Src SH2 domain, and this too is blocked by Csk expression. These data suggest that Gbetagamma subunit-mediated activation of Src family nonreceptor tyrosine kinases can account for the Gi-coupled receptor-mediated tyrosine phosphorylation events that direct recruitment of the Shc and Grb2 adapter proteins to the membrane.

The present paper presents an integrated computer-aided engineering (CAE) approach combining digital imaging, solid modeling, robust design methodology, and finite element analysis in order to conduct a parametric investigation of the design of locked plating systems. The present study allows for understanding the contributions of different design parameters on the biomechanics and reliability of these systems. Furthermore, the present approach will lead to exploration of optimum design parameters that will result in robust system performance. Three-dimensional surface models of cortical and cancellous femoral bone were derived via digital computed tomography (CT) image processing techniques and a medical imaging analysis program. A nine orthogonal array matrix simulation (L9) was conducted using finite element methods to study the effects of the various design parameters on plate performance. The introduced technique was demonstrated and experimentally verified on a case study using a Smith & Nephew PERI- LOC distal femur locking plate and a Synthes Less Invasive Stabilization System (LISS).

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.

Surgical-site infection is a common form of noscomial infection that can occur in fractures following internal fixation. Treatment of these infections has traditionally included preserving stable implants via debridement and antibiotic administration while the fracture is healing. Recent evidence indicated that this algorithm results in less-than-optimal rates of fracture union and infection eradication. The premise for this study is that bacterial removal from fracture implants using the Versajet Hydrosurgery System (Smith & Nephew, Memphis, Tennessee) method is better compared with the bulb syringe and pressurized pulsatile lavage methods. Thirty-two stainless steel, 4-hole, nonlocking, 3.5-mm fracture plates were incubated with Staphylococus aureus and divided into 4 groups. Eight plates in each group underwent irrigation with 1 L of saline using a bulb syringe lavage, pressurized pulsatile lavage, or the Versajet Hydrosurgery System method. Eight plates underwent no irrigation method and served as a control group. The residual bacterial loads following irrigation were quantitatively cultured. Each of the experimental groups had significantly reduced levels of bacteria adherent to the plate following irrigation compared with the control group ( P =.0002). Furthermore, the Versajet Hydrosurgery System was most the effective at bacterial removal, followed by the pressurized pulsatile and bulb syringe lavage techniques ( P =.0002 to P =.0012, respectively). Novel approaches to eradicate bacteria from implants, such as hydrosurgery technology, while maintaining rigid stability of healing fracture, may improve clinical outcomes.

Titanium locking plates are commonly used for periarticular fracture fixation. Early clinical results have been encouraging in their use in treating distal femur and proximal tibia fractures, particularly with the advent of instrumentation for submuscular insertion and percutaneous fixation. A unique feature of titanium locking plates is the phenomenon of cold-welded screws due to titanium being a softer metal. The removal of cold-welded screws in clinical practice can be frustrating. However, it is not commonly reported, as it is often viewed as an insignificant surgical event. Manufacturers promote a strict adherence to using a torque-limiting screwdriver to decrease the risk of cold-welding. Failure to be able to remove titanium screws can be attributed to fracturing or deforming the screw head recess, slippage of the screwdriver in the screw head, fracture of the screwdriver, or inadequate torque provided by the removal instrument. Biomechanical torque studies have shown failure of the screw head recess occurs as permanent deformation by reaming of the recess walls. If the screwdriver has slipped once, additional attempts to drive the screw in or out will produce only one-half of the original maximum torque. Consequently, once slippage has occurred, removal of the screw becomes more difficult. As the screw deforms, changing the screwdriver is futile. Previously described techniques for screw removal are documented in medical literature. First, if slippage of the screwdriver is an issue, the foil from a suture pack may be positioned between the screwdriver and the drive connection which increases the stability of the connection enough to allow for removal. Second, conical extraction screws, available in standard hardware removal sets, can be used to remove stripped screws. It can be difficult to disengage the extraction screw the locking screw

Compartment syndrome is an orthopaedic emergency that can be challenging to diagnose and manage when associated with a tibial plateau fracture. This technique article discusses one- and two-incision fasciotomy surgical techniques, and the surgical decision making and technique modifications when there is an associated tibial plateau fracture.

A computer-aided simulation model is developed to aid in the design and optimization of orthopaedic trauma implants. The developed model uses digital imaging, computer-aided solid modeling, and finite element methods in order to study the effects of various geometric parameters of fixation devices in orthopedic surgery practice. The results of the present simulation model would lead to the determination of the optimum implant design that provides the best match with the geometry of the human femur — reducing the risk of over-stressing bone tissue during implant insertion. The effectiveness of the presented simulation model is demonstrated through the design of intramedullary (IM) nails used in treating femoral shaft fractures. CT scans were taken of forty intact human femora. A technique was developed in order to digitally reconstruct the scans into 3D solid models using image segmentation, surface simplification, and smoothing methods while maintaining accurate representation of the original scans. Each resulting surface model is characterized by a network of nearly equilateral triangles of approximately the same size allowing for quality finite element meshing. Femoral lengths, curvature, shaft diameters, and location of maximum curvature were then quantified. An average geometric model was then generated for the investigated sample by averaging corresponding nodal coordinates in each femur model. Using the average model, a length-standardized function representing the curvature of the medullary canal was derived to create a geometrically optimized IM nail for the entire sample. “Virtual surgery” simulating the insertion process was then performed using finite element methods in order to validate the proposed optimal IM nail design. The results of both the optimum nail and a current nail were compared using the femur having the highest curvature in the sample. The present study shows that the developed simulation model leads to a nail design that reduces the insertion-induced stress within the femur to an acceptable level compared to current nails.Copyright © 2010 by ASME