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PURPOSE OF REVIEW: Although developing PROMs is arduous and measuring their psychometric characteristics is even more so, the number of available PROMs has grown dramatically in the foot and ankle community over the past few years. The psychometric properties of foot and ankle PROMs vary considerably, which could explain why there are so many of them used in the literature. This review aims to shed light on the most commonly used PROMs in foot and ankle literature and assess the evidence supporting their use. RECENT FINDINGS: In this study, very limited evidence was found to support the use of most of the commonly used PROMs in foot and ankle literature, and no evidence was found that supports the use of the most common tool, the AOFAS Clinical Rating System. The quality of the studies examining PROMs was also questioned. Prior to making a conclusive determination regarding each instrument, however, additional research on the evidence is necessary. SUMMARY: It is extremely challenging to perform systematic reviews comparing data across foot and ankle studies, and it is almost impossible to pool such data into high-quality meta-analyses. So, we need a foot and ankle score for measuring trauma-related outcomes, a score for measuring elective procedure outcomes, and a score for measuring pediatric foot and ankle.

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.

Ankle fractures are the fourth most common fracture requiring surgical management. The deltoid ligament is a primary ankle stabilizer against valgus forces. It is frequently ruptured in ankle fractures; however, there is currently no consensus regarding repair. A systematic database search was conducted with Medline, PubMed, and Embase for relevant studies discussing patients with ankle fractures involving deltoid ligament rupture and repair. Screening, quality assessment, and data extraction were performed independently and in duplicate. Data extracted included pain, range of motion (ROM), function, medial clear space (MCS), syndesmotic malreduction, and complications. After screening, 9 eligible studies from 1990 to 2018 were included (N = 508). Compared to nonrepair groups, deltoid ligament repair patients had lower syndesmotic malreduction rates (0%-9% vs 20%-35%, p ≤ .05), fewer implant removals (5.8% vs 41% p ≤ .05), and longer operating time by 16-20 minutes (p ≤ .05). There was no significant difference for pain, function, ROM, MCS, and complication rate (p ≤ .05). In conclusion, deltoid ligament repair offers lower syndesmotic malreduction rates and reduced re-operation rates for hardware removal in comparison to trans-syndesmotic screws. Repair groups demonstrated equivalent or better outcomes for pain, function, ROM, MCS, and complication rates. Other newer syndesmotic fixation methods such as suture-button fixation require further evaluation when compared to the outcomes of deltoid ligament repair. A randomized control trial is required to further examine the outcomes of ankle fracture patients who undergo deltoid ligament repair versus trans-syndesmotic screw fixation.

© The Author(s) 2019. Vascular compromised fractures typically result in a high rate of healing complications, such as avascular necrosis, nonunion, delayed union, and arthritis, which severely affect a patient’s function and quality of life. The purpose of this review was to identify and describe the epidemiology and available treatment options for the most well-known vascular compromised closed fractures. The injuries discussed in detail in this review were scaphoid, lunate, femoral neck, and talar fractures. Current evidence suggests that optimal treatment for vascular compromised fractures is dependent on the degree of fracture displacement and comminution, and the patient’s post-injury functional demands, age, and bone quality. Conservative efforts generally include casting or splinting with a period of immobilization. Surgery is indicated for substantially displaced fractures, patients who require higher functional demands and an earlier return to activity, or if complications occur following nonoperative treatment; however, operative intervention is typically performed for femoral neck fractures regardless of the amount of displacement. Various surgical techniques exist, though internal fixation with screws is a common procedure among these injuries and can be used in combination with other implants, such as plating or Kirschner wires (k-wires), when needed. Severe fracture comminution, poor bone quality, or arthritis can contraindicate the use of screws and more invasive intervention will be required. Bone grafting is done in some cases to enhance vascularity. Salvage procedures exist for patients who develop severe complications, but these will permanently alter the anatomy of the injured area and should be considered a last resort.

Older people with hip fractures are often malnourished at the time of fracture, and subsequently have poor food intake. This is an update of a Cochrane review first published in 2000, and previously updated in 2010.To review the effects (benefits and harms) of nutritional interventions in older people recovering from hip fracture.We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL, MEDLINE, MEDLINE In-ProcessOther Non-Indexed Citations, Embase, CAB Abstracts, CINAHL, trial registers and reference lists. The search was last run in November 2015.Randomised and quasi-randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture where the interventions were started within the first month after hip fracture.Two review authors independently selected trials, extracted data and assessed risk of bias. Where possible, we pooled data for primary outcomes which were: all cause mortality; morbidity; postoperative complications (e.g. wound infections, pressure sores, deep venous thromboses, respiratory and urinary infections, cardiovascular events); and 'unfavourable outcome' defined as the number of trial participants who died plus the number of survivors with complications. We also pooled data for adverse events such as diarrhoea.We included 41 trials involving 3881 participants. Outcome data were limited and risk of bias assessment showed that trials were often methodologically flawed, with less than half of trials at low risk of bias for allocation concealment, incomplete outcome data, or selective reporting of outcomes. The available evidence was judged of either low or very low quality indicating that we were uncertain or very uncertain about the estimates.Eighteen trials evaluated oral multinutrient feeds that provided non-protein energy, protein, vitamins and minerals. There was low-quality evidence that oral feeds had little effect on mortality (24/486 versus 31/481; risk ratio (RR) 0.81 favouring supplementation, 95% confidence interval (CI) 0.49 to 1.32; 15 trials). Thirteen trials evaluated the effect of oral multinutrient feeds on complications (e.g. pressure sore, infection, venous thrombosis, pulmonary embolism, confusion). There was low-quality evidence that the number of participants with complications may be reduced with oral multinutrient feeds (123/370 versus 157/367; RR 0.71, 95% CI 0.59 to 0.86; 11 trials). Based on very low-quality evidence from six studies (334 participants), oral supplements may result in lower numbers with 'unfavourable outcome' (death or complications): RR 0.67, 95% CI 0.51 to 0.89. There was very low-quality evidence for six studies (442 participants) that oral supplementation did not result in an increased incidence of vomiting and diarrhoea (RR 0.99, 95% CI 0.47 to 2.05).Only very low-quality evidence was available from the four trials examining nasogastric multinutrient feeding. Pooled data from three heterogeneous trials showed no evidence of an effect of supplementation on mortality (14/142 versus 14/138; RR 0.99, 95% CI 0.50 to 1.97). One trial (18 participants) found no difference in complications. None reported on unfavourable outcome. Nasogastric feeding was poorly tolerated. One study reported no cases of aspiration pneumonia.There is very low-quality evidence from one trial (57 participants, mainly men) of no evidence for an effect of tube feeding followed by oral supplementation on mortality or complications. Tube feeding, however, was poorly tolerated.There is very low-quality evidence from one trial (80 participants) that a combination of intravenous feeding and oral supplements may not affect mortality but could reduce complications. However, this expensive intervention is usually reserved for people with non-functioning gastrointestinal tracts, which is unlikely in this trial.Four trials tested increasing protein intake in an oral feed. These provided low-quality evidence for no clear effect of increased protein intake on mortality (30/181 versus 21/180; RR 1.42, 95% CI 0.85 to 2.37; 4 trials) or number of participants with complications but very low-quality and contradictory evidence of a reduction in unfavourable outcomes (66/113 versus 82/110; RR 0.78, 95% CI 0.65 to 0.95; 2 trials). There was no evidence of an effect on adverse events such as diarrhoea.Trials testing intravenous vitamin B1 and other water soluble vitamins, oral 1-alpha-hydroxycholecalciferol (vitamin D), high dose bolus vitamin D, different oral doses or sources of vitamin D, intravenous or oral iron, ornithine alpha-ketoglutarate versus an isonitrogenous peptide supplement, taurine versus placebo, and a supplement with vitamins, minerals and amino acids, provided low- or very low-quality evidence of no clear effect on mortality or complications, where reported.Based on low-quality evidence, one trial evaluating the use of dietetic assistants to help with feeding indicated that this intervention may reduce mortality (19/145 versus 36/157; RR 0.57, 95% CI 0.34 to 0.95) but not the number of participants with complications (79/130 versus 84/125).There is low-quality evidence that oral multinutrient supplements started before or soon after surgery may prevent complications within the first 12 months after hip fracture, but that they have no clear effect on mortality. There is very low-quality evidence that oral supplements may reduce 'unfavourable outcome' (death or complications) and that they do not result in an increased incidence of vomiting and diarrhoea. Adequately sized randomised trials with robust methodology are required. In particular, the role of dietetic assistants, and peripheral venous feeding or nasogastric feeding in very malnourished people require further evaluation.

With promising technological advances, ankle arthroplasty has become an alternative to arthrodesis, traditionally the gold standard, for treating end-stage ankle arthritis. We collected knowledge and perceptions on both procedures to determine the need for a patient decision aid for these patients by administering a cross-sectional survey to 103 orthopaedic surgeons. Respondents were predominantly male and 41 to 50 years old. Half of those who stated that they do not perform arthroplasty said this was because they do not have adequate training. Additionally, certain variables were associated with the surgeon's choice of intervention: patient gender, age, body mass index, postoperative activity level, employment type, perceived risk of infection, neurovascular injury or wound complication, risk of developing or pre-existing adjacent arthritis, deformity, malalignment, bone loss or abnormal bone quality, number of prior ankle operations, cause of arthritis, and desire for motion preservation. The majority agreed that they always incorporate patient preferences into their decisions and that a decision aid would be beneficial. This survey revealed that several patient characteristics are influential in the surgeon's preference for either arthroplasty or arthrodesis for end-stage ankle arthritis. Because the majority of surgeons incorporate patient preferences in their decisions and report that a decision aid would be beneficial for informed decision-making in this clinical scenario, this survey identified an unmet need supporting the development of such a tool for these patients.

Background Recent reports from both accreditation bodies in North America highlight problems with current assessment practices in postgraduate medical training. Previous work has shown that educators might be reluctant to report poor performance or fail underperforming trainees. This study explores the barriers perceived by medical educators to providing more meaningful assessment and feedback to trainees. Methods Semistructured interviews were conducted with 22 physician educators. Interviews were audiotaped and transcribed verbatim. Three researchers analyzed the transcripts using a grounded theory approach. Results Participants expressed a reluctance to provide poor assessments or feedback to trainees. Fifty-five percent of the participants reported passing trainees who could have benefited from additional training. Our data revealed a number of barriers which may account for these findings. Implementing more frequent formative assessments could help educators more effectively evaluate trainees and provide feedback, although a shift in the culture of medicine may be required. Conclusion It is imperative that the barriers to effective assessment and feedback identified in this study be addressed to improve postgraduate medical training and enhance patient care.

Importance The risk of developing a surgical site infection after extremity fracture repair is nearly 5 times greater than in most elective orthopedic surgical procedures. For all surgical procedures, it is standard practice to prepare the operative site with an antiseptic solution; however, there is limited evidence to guide the choice of solution used for orthopedic fracture repair. Objective To compare the effectiveness of iodophor vs chlorhexidine solutions to reduce surgical site infections and unplanned fracture-related reoperations for patients who underwent fracture repair. Design, Setting, and Participants The PREP-IT (Program of Randomized Trials to Evaluate Pre-operative Antiseptic Skin Solutions in Orthopaedic Trauma) master protocol will be followed to conduct 2 multicenter pragmatic cluster randomized crossover trials, Aqueous-PREP (Pragmatic Randomized Trial Evaluating Pre-Operative Aqueous Antiseptic Skin Solution in Open Fractures) and PREPARE (Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities). The Aqueous-PREP trial will compare 4% aqueous chlorhexidine vs 10% povidone-iodine for patients with open extremity fractures. The PREPARE trial will compare 2% chlorhexidine in 70% isopropyl alcohol vs 0.7% iodine povacrylex in 74% isopropyl alcohol for patients with open extremity fractures and patients with closed lower extremity or pelvic fractures. Both trials will share key aspects of study design and trial infrastructure. The studies will follow a pragmatic cluster randomized crossover design with alternating treatment periods of approximately 2 months. The primary outcome will be surgical site infection and the secondary outcome will be unplanned fracture-related reoperations within 12 months. The Aqueous-PREP trial will enroll a minimum of 1540 patients with open extremity fractures from at least 12 hospitals; PREPARE will enroll a minimum of 1540 patients with open extremity fractures and 6280 patients with closed lower extremity and pelvic fractures from at least 18 hospitals. The primary analyses will adhere to the intention-to-treat principle and account for potential between-cluster and between-period variability. The patient-centered design, implementation, and dissemination of results are guided by a multidisciplinary team that includes 3 patients and other relevant stakeholders. Discussion The PREP-IT master protocol increases efficiency through shared trial infrastructure and study design components. Because prophylactic skin antisepsis is used prior to all surgical procedures and the application, cost, and availability of all study solutions are similar, the results of the PREP-IT trials are poised to inform clinical guidelines and bring about an immediate change in clinical practice. Trial Registration ClinicalTrials.gov Identifiers:NCT03385304andNCT03523962

Although there is growing evidence supporting posterior-based surgical approaches to open reduction internal fixation (ORIF) of malleolar fractures, the lateral approach still remains the standard of care for this injury. The purpose of this review was to integrate the results of several studies investigating outcomes following posterior-based approaches to the ORIF of malleolar fractures. The literature search was undertaken using PubMed, the Cochrane Library, and Embase. Crude event rates for fracture healing and postoperative complications were calculated. When possible, meta-analyses were conducted to estimate the relative risk of these outcomes between patients treated by posterior-based approaches versus other approaches to ORIF of malleolar fractures. Twenty-two studies were eligible, and 4 studies were included in the meta-analyses. The healing rate was 100% in all patients, regardless of the surgical approach. Overall, 1.26% of patients developed an infection, 0.63% required reoperation, 1.13% experienced aseptic loosening, 5.53% experienced pain after treatment, and 2.52% experienced symptomatic hardware. No malunion or heterotopic ossification was reported in any study. Among patients treated with a posterior-based approach, the most frequently reported complication was infection (2.50%), with lower rates of reoperation and postoperative pain. Patients with trimalleolar fractures experienced slightly poorer outcomes. Patients treated by posterior-based approaches had a significantly increased risk of infection (p = .010) relative to those treated by the lateral approach; patients treated by the lateral approach had a significantly increased risk of pain after surgery (p = .004) and symptomatic hardware (p = .007). This study brought together evidence that posterior-based surgical approaches and non–posterior-based approaches to ORIF are effective in healing malleolar fractures, with significant differences in specific postoperative complications that need to be further explored.

Background: Intra-articular (IA) injections are commonly used to treat knee arthritis pain; however, whether their efficacy generalizes to ankle arthritis remains debatable. We aimed to evaluate the evidence for IA therapies in the management of this patient population. Methods: We performed a literature search for observational and randomized controlled trials (RCTs). Treatments included corticosteroids (CS), hyaluronic acid (HA), platelet-rich plasma (PRP), and mesenchymal stem cells (MSC). We extracted study details, patient demographics, treatment characteristics, efficacy outcomes, and safety. When feasible, data from RCTs were meta-analyzed using a random-effects model and 95% confidence intervals (CIs) were calculated. A P value Results: We identified 27 studies (1085 patients). Ankle OA, rheumatoid arthritis (RA), and hemophilic arthropathy populations were examined. The majority of studies were observational (20 studies); the only RCTs were those evaluating HA. Case series demonstrated favorable results in terms of symptomatic relief with CS, HA, PRP, and MSC injections; however, the effects of CS may only be short term and the evidence on MSCs was limited to 1 study with 6 ankle OA patients. Pooled results (3 RCTs, 109 patients) suggested significantly improved Ankle Osteoarthritis Scale scores with HA over saline at 6 months, with a mean difference of 12.47 points (95% CI 1.18-23.77, P = .03). Conclusion: Evidence from small trials favors HA and PRP injections for the treatment of pain associated with ankle osteoarthritis. However, the relative efficacy of all injectable therapies is far from definitive and warrants further high-quality comparative trials. Level of Evidence: Level III, systematic review.

Olecranon fractures represent 10% of upper extremity fractures. There is a growing body of literature to support the use of plate fixation for displaced olecranon fractures. The purpose of this survey was to gauge Canadian surgeons' practices and preferences for internal fixation methods for displaced olecranon fractures.Using an online survey tool, we administered a cross-sectional survey to examine current practice for fixation of displaced olecranon fractures.We received 256 completed surveys for a response rate of 31% (95% confidence interval [CI] 30.5-37.5%). The preferred treatment was tension band wiring (78.5%, 95% CI 73-83%) for simple displaced olecranon fractures (Mayo IIA) and plating (81%, 95% CI 75.5-85%) for displaced comminuted olecranon fractures (Mayo IIB). Fracture morphology with a mean impact of 3.31 (95% CI 3.17-3.45) and comminution with a mean impact of 3.34 (95% CI 3.21-3.46) were the 2 factors influencing surgeons' choice of fixation method the most. The major deterrent to using tension band wiring for displaced comminuted fractures (Mayo IIB) was increased stability obtained with other methods described by 75% (95% CI 69-80%) of respondents. The major deterrent for using plating constructs for simple displaced fractures (Mayo IIA) was better outcomes with other methods. Hardware prominence was the most commonly perceived complication using either method of fixation: 77% (95% CI 71.4-81.7%) and 76.2% (95% CI 70.6-81.0%) for tension band wiring and plating, respectively.Divergence exists with current literature and surgeon preference for fixation of displaced olecranon fractures.Les fractures de l’olécrâne représentent 10 % des fractures des membres supérieurs. On trouve dans la littérature de plus en plus d’articles à l’appui de l’utilisation d’une fixation avec plaque pour les fractures déplacées de l’olécrâne. Le but de cette enquête était d’évaluer les pratiques et les préférences des chirurgiens canadiens en ce qui concerne les méthodes de fixation internes dans les cas de fractures déplacées de l’olécrâne.À l’aide d’un outil de sondage en ligne, nous avons mené une enquête transversale afin de vérifier les pratiques actuelles en matière de fixation des fractures déplacées de l’olécrâne.Nous avons reçu 256 questionnaires dûment remplis, pour un taux de réponse de 31 % (intervalle de confiance [IC] de 95 % 30,5–37,5 %). Le traitement préféré pour les fractures déplacées simples de l’olécrâne (Mayo IIA) était le cerclage-haubanage (78,5 %, IC de 95 % 73–83 %), et pour les fractures déplacées comminutives de l’olécrâne (Mayo IIB), la fixation par plaque (81 %, IC de 95 % 75,5–85 %) des répondants). Un impact moyen de 3,31 (IC de 95 % 3,17–3,45) exercé par la morphologie de la fracture et un impact moyen de 3,34 (IC de 95 % 3,21–3,46) exercé par la comminution ont été les 2 facteurs ayant le plus influé sur le choix des chirurgiens quant à la méthode de fixation. Le principal argument contre l’utilisation du cerclage-haubanage pour une fracture comminutive déplacée (Mayo IIB) était la stabilité accrue obtenue avec d’autres méthodes décrites par 75 % (IC de 95 % 69–80 %) des participants. Le principal argument contre l’utilisation des plaques pour les fractures simples déplacées (Mayo IIA) était l’obtention de résultats meilleurs avec d’autres méthodes. La complication la plus souvent perçue en lien avec l’une ou l’autre des méthodes de fixation avait trait au matériel : 77 % (IC de 95 % 71,4–81,7 %) et 76,2 % (IC de 95 % 70,6–81,0 %) pour le cerclage- haubanage et la fixation par plaque, respectivement.Il existe des divergences entre la littérature actuelle et les préférences des chirurgiens en ce qui concerne la fixation des fractures déplacées de l’olécrâne.

Objective Objective assessment of resident performance continues to task program directors (PDs) with a formidable challenge. This study evaluated attitudes toward the Orthopaedic In-Training Examination (OITE), compared its value between countries, assessed its value against other metrics of resident performance, and examined program and resident factors predictive of high achievement. Design Survey. Setting Orthopedic surgery residency programs across the United States and Canada. Participants One hundred sixty-six PDs and 945 residents. Results Eighty-eight PDs and 331 residents completed the surveys (response rates, 54% and 35%, respectively). PDs and residents in the United States assigned greater importance to the OITE than did those in Canada and reported OITE scores from the United States were significantly higher. PDs in the United States reported greater consequences for residents with poor scores than did PDs from Canada, including remediation and reprimand. Observed structured clinical examinations, internal examinations, and in-training evaluation reports were assigned greater importance by PDs and residents in Canada, but low or no importance by those in the United States. In preparation for the OITE, residents strongly favored prior OITE and American Academy of Orthopaedic Surgeons self-assessment questions, the ‘AAOS Comprehensive Orthopaedic Review' textbook, the Journal of the American Academy of Orthopaedic Surgeons , and an OITE-based multiple-choice question website. Regression analysis identified resident and program emphasis on OITE studying and higher level of training as positive predictors for higher OITE scores. Conclusions The OITE is more important to PDs and residents in the United States than it is in Canada, and the reported OITE scores reflect these attitudes. PDs in Canada also employ a greater diversity of evaluative tools, a practice in keeping with recent advances toward competency-based medical education. The findings of this report may help PDs be aware of alternative methods of formative resident evaluation and ultimately improve the training of future independent surgeons.

Background: The anterior talofibular ligament (ATFL) is the ligament most commonly injured during ankle sprains. Objective: The purpose of this investigation was to assess the sensitivity of Magnetic Resonance (MR) imaging for ATFL with open surgery, Brostrom-Gould surgical interventional considered the gold standard. Methods: A retrospective chart review using Operating Room (OR) and MR reports from April 2008-November 2009 led to a review of 137 charts, with 15 cases meeting the inclusion criteria. Results: The sensitivity for ATFL tears irrespective of extent of the tear was 93%. For full thickness ATFL tears, 10 were found to be positive on MR but 13 on OR with a sensitivity of 77%. Of the three missed cases, 2 were described as sprain injuries and the other normal using MRI. Conclusion: The recommendations for MR assessment of ankle injury include use of dedicated sequences and understanding the “pseudoband” concept. The two full thickness and two partial thickness tears on OR described as sprain injuries on MRI had a band of inflammatory granulation tissue. This tissue accounted for the appearance of the thick continuous band at MRI, the pseudoband. This study reaffirms the usefulness of MR in determining ATFL tears, aiding surgical decision making.

BACKGROUND Wound management in open fractures remains an area of controversy. Although numerous protocols for soft tissue coverage and fracture fixation have been proposed, problems with infection, delayed healing, and prolonged disability have remained. The purpose of this systematic review was to critically examine the timing of flap coverage in open fractures and its impact on bone union, infections, complication rates, and duration of hospital stay. METHODS We comprehensively searched the literature for relevant studies across CINAHL, EMBASE, MEDLINE, and the Cochrane databases. The Orthopaedic Trauma Association and Canadian Orthopedic Association proceedings were also searched. Two independent reviewers screened and assessed abstracts. Articles were selected using specific inclusion criteria and were categorized as "early," "intermediate," or "late" based on their timing of flap coverage. Methodological quality of included studies was assessed using the Newcastle-Ottawa Scale for Cohort Studies. RESULTS Of 83 potentially eligible studies, 20 articles were included in the final analysis (agreement kappa = 0.83). Of these, eight studies evaluated "early" flap coverage, nine studies evaluated "intermediate" flap coverage, and nine studies evaluated "late" flap coverage. Early flap coverage was associated with lower infection rates (p < 0.0001) and lower complications (p = 0.15). CONCLUSIONS The results of this systematic review (level III evidence) suggest that any delay in flap coverage may provide suboptimal bone healing, infection, and complication rates. It is recommended that methodologically sound randomized controlled trials be performed comparing "early" flap coverage time points to determine optimal outcomes for bone union, infection, and hospital stay as none exist to date.

Background Open fractures are an important source of morbidity and are associated with delayed union, nonunion, and infection. Preventing infection through meticulous irrigation and debridement is an important goal in management, and different lavage fluids and irrigation techniques (e.g., high- or low-pressure lavage) have been described for this purpose. However, there are a limited number of randomized trials comparing irrigating solutions or irrigating technique. We compared the use of castile soap versus normal saline and high- versus low-pressure pulsatile lavage on the rates of reoperations and complications in patients with open fracture wounds. Methods We conducted a multicenter, blinded, randomized 2 × 2 factorial pilot trial of 111 patients in whom an open fracture wound was treated with either castile soap solution or normal saline and either high- or low-pressure pulsatile lavage. The primary composite outcome of reoperation, measured at 12 months after initial operative procedure, included infection, wound healing problems, and nonunion. Planned reoperations were not included. Secondary outcomes included all infection, all wound healing problems, and nonunion as well as functional outcomes scores (EuroQol-5 dimensions and short form-12). Results Eighty-nine patients completed the 1-year follow-up. Among all patients, 13 (23%) in the castile soap group and 13 (24%) in the saline group had a primary outcome event (hazard ratio, 0.91, 95% confidence interval: 0.42-2.00, p = 0.52). Sixteen patients (28%) in the high-pressure group and 10 patients (19%) in the low-pressure group had a primary outcome event (hazard ratio 0.55, 95% confidence interval: 0.24-1.27, p = 0.17). Functional outcome scores showed no significant differences at any time point between groups. Conclusion The fluid lavage of open wounds pilot randomized controlled trial demonstrated the possibility that the use of low pressure may decrease the reoperation rate for infection, wound healing problems, or nonunion. We have demonstrated the desirability and feasibility of a definitive trial examining the effects of alternative irrigation approaches.

Background: From 1999 to 2004, an estimated 653,000 women in Canada were either physically or sexually abused by their current or previous intimate partners. We aimed to determine the proportion of women presenting to orthopaedic fracture clinics for the treatment of musculoskeletal injuries who had experienced intimate partner violence, defined as physical, sexual, or emotional abuse, within the past twelve months. Methods: We completed a cross-sectional study of 282 injured women attending two Level-I trauma centers in Canada. Female patients presenting to the orthopaedic fracture clinics anonymously completed two previously developed self-reported written questionnaires, the Woman Abuse Screening Tool (WAST) and the Partner Violence Screen (PVS), to determine the prevalence of intimate partner violence. The questionnaire also contained questions that pertain to the participant’s demographic characteristics, fracture characteristics, and experiences with health-care utilization. Results: The overall prevalence of intimate partner violence (emotional, physical, and sexual abuse) within the last twelve months was 32% (95% confidence interval, 26.4% to 37.2%). Twenty-four (8.5%) of the injured women disclosed a history of physical abuse in the past year. Seven women indicated that the cause for their current visit was directly related to physical abuse. Ethnicity, socioeconomic status, and injury patterns were not associated with abuse. Of the twenty-four women who reported physical abuse, only four had been asked about intimate partner violence by a physician; none of these physicians were the treating orthopaedic surgeons. Conclusions: Our study suggests a high prevalence of intimate partner violence among female patients with injuries who presented to two orthopaedic fracture clinics in Ontario. Surgeons and health-care personnel in fracture clinics should consider intimate partner violence when interacting with injured women.

This article provides an overview of the biology behind the use of electrical stimulation in fracture healing and discusses the current methods of electrical bone growth stimulation. In addition, we review the best available clinical evidence for the use of electrical stimulation in the treatment of delayed and nonunions of fractures. Our search identified 4 meta-analyses on the use of electrical stimulation on fracture healing. The most methodologically rigorous and recent meta-analysis suggests that the current evidence is insufficient to conclude a benefit of electromagnetic stimulation in improving the rate of union in patients with a fresh fracture, osteotomy, delayed union, or nonunion. The other 3 meta-analyses that we identified suggested a more significant treatment effect from electrical stimulation. Although the evidence supporting electrical stimulation does trend in favor of its use to help achieve bony union, further large, multicenter, randomized, controlled trials are required to resolve the current uncertainty surrounding the use of electrical stimulation and fracture healing.

Prognostic studies are designed to investigate factors that impact the outcome of a disease or its treatment. These factors include, but are not limited to, inherent patient characteristics, the state of the disease, and severity of symptoms. The results of prognostic studies can be used to guide the treatment of patients with similar conditions and overall characteristics. It is the purpose of this paper to provide an outline of how to perform an unbiased appraisal of a prognostic study, allowing the physician to assess the applicability of the results to their patient and thereby assist with decision making in clinical practice.

Background: Despite the large number of fracture outcome studies, there remains variability in the definitions of fracture-healing. It is unclear how orthopaedic surgeons are diagnosing and managing delayed unions and nonunions in clinical practice. We aimed to explore the current opinions of orthopaedic surgeons with regard to defining, diagnosing, and treating delayed unions and nonunions in extremity fractures. Methods: We developed a survey using previous literature, key informants in the field of orthopaedic surgery, and a sample-to-redundancy strategy. Our final survey contained four sections and twenty-nine questions focusing on demographics and surgical experience, definitions of fracture union, prognostic factors for union, and the need for clinical trials. The Internet-based survey and follow-up e-mails were continued until our a priori sample size of a minimum of 320 completed and eligible responses were collected. Results: Three hundred and thirty-five surgeons completed the survey. The typical respondent was a North American, male orthopaedic surgeon or consultant over the age of thirty years who had completed trauma fellowship training, worked in an academic practice, supervised residents, and had more than six years of experience in treating orthopaedic injuries. Most surgeons endorsed a lack of standardization in definitions for delayed unions (73%) and nonunions (55%); almost all agreed that defining a delayed union and nonunion should be done on the basis of both radiographic and clinical criteria (88%). Most respondents believed that the degree of soft-tissue injury (approximately 93%), smoking history (approximately 82%), and vascular disease (approximately 76%) increased the risk of healing complications. Conclusions: Surgeons use similar prognostic factors to define and assess delayed unions and nonunions, but there is a lack of consensus in the definitions of delayed union and nonunion. The need for standardization and future randomized trials was strongly endorsed.