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The purpose of this study was to investigate the association between pre-operative anemia and prolonged hospital stay among geriatric patients with operative femoral neck fractures. This retrospective cohort study was performed at a level I trauma center and included geriatric patients with femoral neck fractures (OTA/AO 31) and operative treatment with Current Procedural Terminology code 27236. Exclusion criteria were admission to the intensive care unit, evacuation of subdural hematoma, and conditions requiring exploratory laparotomy. A total of 207 individuals, with data collected between January 2015 and August 2019 and age 65 years and older, were included in the analysis. Linear regression was used to evaluate the association between anemia and length of stay adjusting for potential confounders. Anemia was defined using preoperative hematocrit. The primary outcome was prolonged length of stay, defined as 5 or more days. The group was 65% women. The mean age was 80.2 years (range, 64–98 years). The majority (61%) of patients had anemia. American Society of Anesthesiologists classification was associated with preoperative anemia ( P =.02). Patients with anemia had a 16% higher risk of prolonged length of stay compared with patients without anemia (81% vs 65%, P =.009). In the linear regression model, preoperative hematocrit was associated with length of stay ( P =.032) when adjusted for sex, age, preoperative tranexamic acid, preoperative hemoglobin, postoperative hemoglobin, and postoperative hematocrit. Length of stay was approximately 1 week in this study, with anemia being a statistically significant risk factor for prolonged length of stay. Health care providers and administrators can consider anemia on admission when predicting length of stay. [ Orthopedics . 202x;4x(x):xx–xx.]

To evaluate the effects of prophylactic piperacillin-tazobactam (PT) on inpatient acute kidney injury (AKI) and fracture-related infection (FRI) in patients with open fractures.Level 1 trauma center.We reviewed 358 Gustilo-Anderson type II and III open fractures at our institution from January 2013 to December 2017.Administration of PT (PT group) or antibiotics other than PT (historical control group) during the first 48 hours of arrival for open fracture antibiotic prophylaxis.Rates of inpatient AKI and FRI within six months after definitive fixation.There were 176 patients in the PT group and 182 patients in the historical control group. The PT group had worse American Society of Anesthesiologists (ASA) class (p=0.004) and injury severity scores (p0.001), a higher average number of debridements prior to closure/coverage (p=0.043), as well as higher rates of gross soil contamination (p=0.049) and staged procedures (p=0.008) compared to historical controls.There was no difference in the rate of AKI between the PT and historical control groups (5.7 vs 2.7%, p=0.166), nor when stratified by Gustilo-Anderson fracture classification (Type II: 5.8 vs 3.6%, p=0.702; Type III: 5.6 vs 2.0%, p=0.283). There was no significant difference in the rate of FRI between the PT and historical control groups (23.6 vs. 19.6%, p=0.469).The use of PT in prophylactic antimicrobial treatment in patients with Gustilo-Anderson type II and III open fractures does not increase the rate of AKI or FRI. We believe PT can be used as an effective monotherapy in these patients without an increased risk of renal injury, but future investigations are necessary.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

To assess ballistic femoral shaft fracture outcomes in comparison with closed and open femoral shaft fractures sustained by blunt mechanisms. We hypothesized that ballistic femoral shaft fractures would have similar outcomes to blunt open fractures.Retrospective cohort study.Academic Level I trauma center.Patients 16 years and older presenting with ballistic (140), blunt closed (317), or blunt open (71) femoral shaft fractures.Unplanned return to operating room, fracture-related infection, soft tissue reconstruction, nonunion, implant failure, length of stay, Injury Severity Scores, hospital charges, and compartment syndrome.A total of 528 femoral shaft fractures were identified. A group of 140 ballistic fractures and comparison groups of all femoral shaft fractures sustained by blunt mechanisms and treated with intramedullary nailing were included in the analysis. Among the 2 subgroups of nonballistic injuries, 317 were blunt closed fractures and 71 were blunt open fractures. The ballistic group was associated with a 3-fold increase in overall complications (30%) compared with the blunt closed group (10%, P0.001), had a higher occurrence of thigh compartment syndrome (P0.001), and required more soft tissue reconstruction (P0.001) than either of the blunt fracture groups.Ballistic femoral shaft fractures do not perfectly fit with blunt closed or open femoral fractures. A high index of suspicion for the development of thigh compartment syndrome should be maintained in ballistic femoral shaft fractures. The overall rates of nonunion and infection were comparable between all groups, but the all-cause complication rate was significantly higher in the ballistic group compared with the blunt closed group.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Fusion of the talonavicular joint has proven challenging in literature. The optimal surgical approach for talonavicular arthrodesis is still uncertain. This study compares the amount of physical joint preparation between dorsal and medial approaches to the talonavicular joint. Methods Twenty fresh frozen cadaver specimens were randomly assigned to receive either a dorsal or medial operative approach to the talonavicular joint. The joint surface was prepared, and the joint was disarticulated. Image analysis, using ImageJ, was performed by two blinded reviewers to assess the joint surface preparation and this was compared by surgical approach. Results The dorsal approach had a higher median percentage of talar and total talonavicular joint surface area prepared (75% vs. 59% (p = .007) and 82% vs. 70% (p = .005)). Irrespective of approach, the talus was significantly more difficult to prepare than the navicular (62% vs 88% (p = .001)). Conclusion The dorsal approach provides superior talonavicular joint preparation. The lateral ¼th of the talar head was the most difficult surface to prepare, and surgeons performing double or triple arthrodesis may prepare the lateral talar head from the lateral approach. Level of evidence Level V.

Understanding how per- and poly-fluoroalkyl substances (PFAS) are transported is critical to site characterization, monitoring, risk assessment, and remediation planning. This includes an understanding of PFAS retention and release at air-water interfaces. These interfaces exist throughout the vadose zone, but can also exist as trapped air bubbles created by water table fluctuations, recharge, and biogenic gas production. In addition to being directly applicable to transport through trapped gas zones at PFAS-impacted sites, laboratory experiments using emplaced trapped gas (quasi-saturated conditions) provide a controlled method to investigate PFAS behavior, including the effects of different PFAS, concentrations, and mixtures. In this study, a series of laboratory experiments was conducted using one-dimensional sand-packed columns (20 cm × 7 cm dia.). Trapped air was emplaced by sequential drainage and imbibition to create quasi-saturated conditions. Each experiment included separate injections of non-reactive tracer (NaCl) and PFAS solutions through both water-saturated and quasi-saturated columns. A clean, low organic carbon sand was used to eliminate solid-phase sorption (verified through comparison of non-reactive tracer and PFAS breakthrough in the water-saturated columns) and to isolate the effect of air-water interfaces. Experiments were conducted using single-component solutions of PFOA, PFOS and 6:2 FTS, as well as mixtures of those PFAS, at concentrations of 0.1-1 mg/L. Experiments were also conducted using diluted aqueous film-forming foam (AFFF) solutions. Measured retardation factors in triplicate experiments were used to estimate air-water partitioning coefficients.The results showed that PFAS breakthrough was significantly delayed in the presence of trapped air bubbles. Breakthrough delay was greater for PFOS than for PFOA or 6:2 FTS, and was greater for lower PFAS concentrations, for the range of concentrations used in these experiments. For PFAS mixtures, differences in retention were sufficient to completely separate breakthrough (i.e., PFOA and 6:2 FTS achieved complete breakthrough prior to any PFOS arrival) even over short (20 cm) distances. However, the behavior of each PFAS tested was altered by the presence of other PFAS, with PFOA and 6:2 FTS experiencing earlier breakthrough at higher concentrations (concentration overshoot) in the presence of PFOS. Mixture effects were also observed for branched and linear PFOS isomers, and for AFFF solutions, which was further complicated by the presence of hydrocarbon surfactants. The experimental results will be presented along with numerical simulations of PFAS transport subject to air-water partitioning, both to interpret the behavior of PFAS mixtures in experimental systems and to explore the implications of mixture transport in more complex field scenarios.

Per- and polyfluoroalkyl substances (PFAS) are a diverse group of manmade, fluorinated organic chemicals that gained notoriety for their diverse application, widespread distribution in the environment and toxicity. One of the main sources of PFAS to the environment is through aqueous film forming foam (AFFF), intended for use on fuel fires. AFFF may enter the environment through system testing, training activities, emergency use or accidental release. When AFFF enters the environment PFAS readily adsorb to porous media through hydrophobic and electrostatic interactions. As a result, PFAS impacted porous media may act as a long-term source of contamination to groundwater, potentially influencing water resources and human health. There is a demand for effective treatment of PFAS impacted porous media. Ball milling has emerged as a potential treatment option for PFAS, however, the viability of treating AFFF impacted porous media has been seldom explored. In this work four AFFF formulations were amended onto silica sand and milled without and with the use of potassium hydroxide (KOH) as a co-milling reagent. Six hour milling trials were conducted using a planetary ball mill with stainless steel grinding media. Significant destruction of perfluorosulfonic acids, perfluorocarboxylic acids (PFCAs), fluorotelomer sulfonates, fluorotelomer betaines and fluorotelomer sulfonamido betaines was observed. With the use of KOH as a co-milling reagent the total PFAS destruction percentage in all four AFFFs exceeded 90%. Greater destruction of PFAS was observed in fluorotelomer dominant AFFFs when compared to perfluoroalkyl acid dominant AFFFs. PFCAs and soluble fluoride were identified as destruction byproducts. KOH as a co-milling reagent had the effect of reducing PFCA byproduct formation and increasing fluoride recovery in three of four AFFFs. Fluoride recoveries indicate PFAS molecule defluorination occurs by ball milling. When PFAS in AFFF is compared to PFAS destruction in single analyte trials, less destruction is observed, displaying the necessity of evaluating realistic AFFF contamination events over single or multi analyte mixtures.

OBJECTIVE To assess the risk factors associated with deep infection after operative treatment of peritalar fracture dislocations. DESIGN A retrospective study was performed to identify patients who had operative treatment of a peritalar fracture dislocation over an 11-year period (2008-2019). SETTING Level 1 trauma center. PARTICIPANTS Patients were identified by review of all surgical billing that included open reduction of peritalar dislocation. Minimum follow-up for inclusion was 3 months or the outcome of interest. A total of 178 patients were identified and 154 patients met inclusion criteria. MAIN OUTCOME The primary outcome was deep infection, defined as return to the operating room for debridement with positive cultures. RESULTS A total of 19 (12.3%) patients developed a post-operative deep infection. The most common associated fractures were talus (47%), calcaneus (33%), and fibula (9%). The infected group was significantly older (47.2 vs 39.5 years, p=0.03). Patients undergoing operative management for peritalar fracture dislocations with current smoking were found to have significantly higher odds of postoperative deep infection (74 vs 34%, aOR=7.4, 95% CI, 2.3-24.1, p=0.001). There was a significantly higher risk of infection in patients with a Gustilo-Anderson type 3 open fractures (32 vs 12%, aOR=5.7, 95% CI, 1.6-20.3, p=0.007). The infected group had high rates of below knee amputation when compared to the group without infection (47 vs 1%, p< 0.001). CONCLUSION In our retrospective study, risk factors for infection after peritalar fracture dislocation included older age, smoking, and Gustilo-Anderson type 3 open fracture. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The transport of per- and polyfluoroalkyl substances (PFAS) in soil and groundwater is important for site investigation, risk characterization, and remediation planning. The adsorption of PFAS at air-water interfaces has been shown to significantly contribute to PFAS retention, with subsequent effects on concentrations and the time scales of transport. In this study, column experiments were conducted to investigate the transport of perfluorooctanesulfonic acid (PFOS), perfluorooctanoic acid (PFOA), and 6:2 fluorotelomer sulfonate (6:2 FTS) individually and in binary mixtures in the presence of a trapped gas phase, using clean sands to isolate adsorption to air-water interfaces. Consistent with previous studies, the transport of PFOS, PFOA, and 6:2 FTS was retarded by adsorption at the air-water interface, with greater retention of PFOS due to its higher affinity for the air-water interface. Chromatographic separation occurred in the experiments using binary mixtures of PFOS and PFOA, with greater retention at lower influent concentrations. The mixture experiments also showed enhanced breakthrough of PFOA in the presence of PFOS, where effluent concentrations of PFOA were temporarily greater than the influent concentration prior to the breakthrough of PFOS. This enhanced breakthrough was attributed to competition between PFOS and PFOA for adsorption to the air-water interface.

Background: There is limited literature comparing the publications on ankle arthrodesis (AA) and total ankle arthroplasty (TAA) in the setting of hemophilic arthropathy. Our objective is to systematically review the existing literature and to assess ankle arthroplasty as an alternative to ankle arthrodesis in this patient population. Methods: This systematic review was conducted and presented according to the PRISMA statement standards. A search was conducted on March 7-10, 2023, using MEDLINE (via PubMed), Embase, Scopus, ClinicalTrials.gov, CINAHL Plus with Full Text, and the Cochrane Central Register of Controlled Studies. This search was restricted to full-text human studies published in English, and articles were screened by 2 masked reviewers. Systematic reviews, case reports with less than 3 subjects, letters to the editor, and conference abstracts were excluded. Two independent reviewers rated study quality using the MINORS tool. Results: Twenty-one of 1226 studies were included in this review. Thirteen articles reviewed the outcomes associated with AA in hemophilic arthropathy whereas 10 reviewed the outcomes associated with TAA. Two of our studies were comparative and reviewed the outcomes of both AA and TAA. Additionally, 3 included studies were prospective. Studies showed that the degree of improvement in American Orthopaedic Foot & Ankle Society hindfoot-ankle score, visual analog scale pain scores, and the mental and physical component summary scores of the 36-Item Short Form Health Survey were similar for both surgeries. Complication rates were also similar between the 2 surgeries. Additionally, studies showed a significant improvement in ROM after TAA. Conclusion: Although the level of evidence in this review varies and results should be interpreted with caution, the current literature suggests similar clinical outcomes and complication rates between TAA and AA in this patient population.

To determine risk factors for deep infection and conversion total hip arthroplasty (THA) after operative management of combined pelvic ring and acetabular injuries.Retrospective case control study.Level 1 trauma center.We reviewed 150 operative combined pelvic ring and acetabular injuries at our institution from 2010 to 2019, with an average follow-up of 690 (90-3282) days.Deep infection and conversion THA.Patients who developed deep infection (N = 17, 11.3%) had higher rates of hip dislocation ( P = 0.030), intraoperative transfusion ( P = 0.030), higher body mass index (BMI) ( P = 0.046), increased estimated blood loss ( P0.001), more intraoperative units transfused ( P = 0.004), and longer operative times ( P = 0.035). Of the 84 patients with 1-year follow-up, 24 (28.6%) required conversion to THA. Patients requiring conversion THA were older ( P = 0.022) and had higher rates of transverse posterior wall fracture pattern ( P = 0.034), posterior wall involvement ( P0.001), hip dislocation ( P = 0.031), wall comminution ( P = 0.002), and increased estimated blood loss ( P = 0.024). The order of the pelvic ring versus acetabular fixation did not affect rates of conversion to THA ( P = 0.109). Multiple logistic regression showed that an increased number of intraoperative units transfused [adjusted odds ratio (aOR) = 1.56, 95% confidence interval (CI) = 1.16-2.09, P = 0.003] and higher BMI (aOR = 1.10, 95% CI = 1.01-1.16, P = 0.024) were independently associated with an increased odds of deep infection. Posterior wall involvement was independently associated with an increased odds of conversion THA (aOR = 5.73, 95% CI = 1.17-27.04, P = 0.031).Rates of deep infection and conversion THA after operative fixation of combined injuries were 11.3% and 28.6%, respectively. Higher average BMI and number of intraoperative units of blood transfused were independently associated with deep infection, whereas posterior wall involvement was independently associated with conversion to THA in these patients.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

There is a need for destructive technologies for per- and polyfluoroalkyl substances (PFAS) in soil. While planetary ball mill have been shown successful degradation of PFAS, there are issues surrounding scale up (maximum size is typically 0.5 L cylinders). While having lower energy outputs, horizontal ball mills, for which scale up is not a limiting factor, already exist at commercial/industrial sizes from the mining, metallurgic and agricultural industries, which could be re-purposed. This study evaluated the effectiveness of horizontal ball mills in degrading perfluorooctanesulfonate (PFOS), 6:2 fluorotelomer sulfonate (6:2 FTSA), and aqueous film forming foam (AFFF) spiked on nepheline syenite sand. Horizontal ball milling was also applied to two different soil types (sand dominant and clay dominant) collected from a firefighting training area (FFTA). Liquid chromatography tandem mass spectrometry was used to track 21 target PFAS throughout the milling process. High-resolution accurate mass spectrometry was also used to identify the presence and degradation of 19 non-target fluorotelomer substances, including 6:2 fluorotelomer sulfonamido betaine (FtSaB), 7:3 fluorotelomer betaine (FtB), and 6:2 fluorotelomer thioether amido sulfonate (FtTAoS). In the presence of potassium hydroxide (KOH), used as a co-milling reagent, PFOS, 6:2 FTSA, and the non-target fluorotelomer substances in the AFFF were found to undergo upwards of 81%, 97%, and 100% degradation, respectively. Despite the inherent added complexity associated with field soils, better PFAS degradation was observed on the FFTA soils over the spiked NSS, and more specifically, on the FFTA clay over the FFTA sand. These results held through scale-up, going from the 1 L to the 25 L cylinders. The results of this study support further scale-up in preparation for on-site pilot tests.

Traumatic hemipelvectomy (THP) is a catastrophic injury associated with high-energy trauma and high mortality. THP has been defined as a complete dislocation of the hemipelvis, often with disruption through the symphysis pubis and sacroiliac joint with concurrent traumatic rupture of the iliac vessels. Despite recent advances in prehospital resuscitative techniques, the true incidence of THP is difficult to ascertain because many patients die before hospital arrival. The leading causes of death associated with THP include blood loss, infection, and multiple system organ failure. Recognition and immediate intervention for these injuries is imperative for survival. The initial assessment includes a thorough physical examination assessing for signs of arterial damage and other associated injuries. Hemorrhage control and vigorous resuscitation should be prioritized to combat impending exsanguination. Emergent amputation has been found to be a lifesaving operation in these patients. The basis of this approach is rooted in achieving complete hemostasis while reducing complication rates. Understanding the nature of these massive pelvic injuries, the role of early amputation, and the importance of subspecialty communication can improve survivability and optimize patient outcomes.

Background: This study investigated the outcomes of coronavirus disease (COVID-19)-positive patients undergoing hip fracture surgery using a national database. Methods: This is a retrospective cohort study comparing hip fracture surgery outcomes between COVID-19 positive and negative matched cohorts from 46 sites in the United States. Patients aged 65 and older with hip fracture surgery between March 15 and December 31, 2020, were included. The main outcomes were 30-day all-cause mortality and all-cause mortality. Results: In this national study that included 3303 adults with hip fracture surgery, the 30-day mortality was 14.6% with COVID-19-positive versus 3.8% in COVID-19-negative, a notable difference. The all-cause mortality for hip fracture surgery was 27.0% in the COVID-19-positive group during the study period. Dicussion: We found higher incidence of all-cause mortality in patients with versus without diagnosis of COVID-19 after undergoing hip fracture surgery. The mortality in hip fracture surgery in this national analysis was lower than other local and regional reports. The medical community can use this information to guide the management of hip fracture patients with a diagnosis of COVID-19.

Pediatric hallux valgus (PHV), while relatively rare, is still often encountered by general pediatricians. Herein, we concisely summarize the existing literature regarding the pathogenesis, associated conditions, clinical diagnosis, radiographic characteristics, conservative management, and surgical management of PVH. Though PHV is generally considered benign, the progression of hallux valgus can result in complications. The presence of an open physis in the pediatric age group delineates first line treatment choices, whenever possible, as nonoperative. The general exception to this recommendation is for children with neuromuscular and connective tissues disease who may benefit from earlier surgical management. If conservative approaches fail prior to skeletal maturity, the risk of recurrence and need for revision surgery should be discussed with patients and their families before surgical referral is made. The current review was conducted to aid primary care providers in better understanding the pathogenesis, associated conditions, and intervention options available to manage PHV.

Introduction: Osteoporosis is a critical public health issue with substantial morbidity and healthcare costs. Resident education on osteoporosis is not standardized. Little is known about the barriers to osteoporosis treatment and the usefulness of educational programming from the perspective of orthopaedic residency program directors (PDs). Methods: This study aims to evaluate the current state and perception of bone health education from the perspective of orthopaedic residency PDs. Therefore, a self-designed 29-question online survey was sent to 129 PDs in the United States to assess bone health education. The information, collected from August to October 2020, included program characteristics, participation in the American Orthopaedic Association’s Own the Bone (AOA/OTB) program or any fracture liaison service (FLS) program, availability of faculty, potential barriers, and educational resources. Data collection was performed anonymously with a 47% response rate. Results: The results were compared between programs that used the AOA/OTB program (30%) or any FLS program (28%) (58% OTB or any FLS) vs. programs that did not have any program (42%). Subsequent subanalysis was performed comparing AOA/OTB vs. any FLS vs. no program. Programs that did not have any FLS were least likely to have a formal education syllabus (p = 0.01). When comparing clinical education of residents on bone health, 64% of programs without any system did not provide any formal clinical exposure such as a bone health clinic vs. assessment in patients with fracture compared with 24% of OTB programs and 44% of programs with any FLS (p = 0.02). When asked about desired resources, 47% would find a bone health rotation useful. Among all PDs, 60% support the concept of a 5-year AOA Council of Orthopaedic Residency Directors (CORD)/OTB osteoporosis curriculum. Discussion: The key findings were that institutions including OTB or any FLS in their programs had better availability of specialty consultants, faculty, and a FLS coordinator.

Proximal humerus fractures (PHFs) are common, and their incidence is increasing as the population ages. Despite this, postoperative rehabilitation remains unstandardized and little is known about surgeon preferences. The aim of this study was to assess differences in postoperative rehabilitation preferences and patient education between orthopedic trauma and shoulder surgeons.An electronic survey was distributed to members of the Orthopaedic Trauma Association and the American Shoulder and Elbow Surgeons to assess differences in postoperative rehabilitation preferences and patient counseling. Descriptive statistics were reported for all respondents, trauma surgeons, and shoulder surgeons. Chi-square and unpaired 2-sample t tests were used to compare responses. Multinomial regression was used to further elucidate the influence of fellowship training independent of confounding characteristics.A total of 293 surgeons completed the survey, including 172 shoulder and 78 trauma surgeons. A greater proportion of trauma surgeons preferred an immediate weightbearing status after arthroplasty compared to shoulder surgeons (45% vs. 19%, P = .003), but not after open reduction and internal fixation (ORIF) (62% vs. 75%, P = .412). A greater proportion of shoulder surgeons preferred home exercise therapy taught by the physician or using a handout following reverse shoulder arthroplasty (RSA) (21% vs. 2%, P = .009). A greater proportion of trauma surgeons began passive range of motion (ROM)2 weeks after 2-part fractures (70% vs. 41%, P .001). Conversely, a greater proportion of shoulder surgeons began passive ROM between 2 and 6 weeks for 2-part (57% vs. 24%, P .001) and 4-part fractures (65% vs. 43%, P = .020). On multinomial regression analysis, fellowship training in shoulder surgery was associated with preference for a nonweightbearing duration of12 weeks vs. 6-12 weeks after ORIF. Similarly, fellowship training in shoulder surgery was associated with increased odds of preferring a nonweightbearing duration of6 weeks vs. no restrictions and12 weeks vs. 6-12 weeks after arthroplasty. Training in shoulder surgery was associated with greater odds of preferring a nonweightbearing duration prior to beginning passive ROM of 2-6 weeks vs.2 weeks or6 weeks for 2-part fractures, but not 4-part fractures.Trauma surgeons have a more aggressive approach to rehabilitation following operative PHF repair compared to shoulder surgeons regarding time to weightbearing status and passive ROM. Given the increasing incidence of PHFs and substantial variations in reported treatment outcomes, differences in rehabilitation after PHF treatment should be further evaluated to determine the role it may play in the outcomes of treatment studies.

Proximal humerus fractures (PHFs) are managed with open reduction and internal fixation (ORIF), hemiarthroplasty (HA), reverse shoulder arthroplasty (RSA), or nonoperatively. Given the mixed results in the literature, the optimal treatment is unclear to surgeons. The purpose of this study was to survey orthopedic shoulder and trauma surgeons to identify the patient- and fracture-related characteristics that influence surgical decision-making.We distributed a 23-question closed-response email survey to members of the American Shoulder and Elbow Surgeons and Orthopaedic Trauma Association. Questions posed to respondents included demographics, surgical planning, indications for ORIF and arthroplasty, and the use of surgical augmentation with ORIF. Numerical and multiple-choice responses were compared between shoulder and trauma surgeons using unpaired t-tests and χRespondents included 172 shoulder and 78 trauma surgeons. When surgery is indicated, most shoulder and trauma surgeons treat 2-part (69%) and 3-part (53%) PHFs with ORIF. Indications for managing PHFs with arthroplasty instead of ORIF include an intra-articular fracture (82%), bone quality (76%), age (72%), and previous rotator cuff dysfunction (70%). In patients older than 50 years, 90% of respondents cited a head-split fracture as an indication for arthroplasty. Both shoulder and trauma surgeons preferred RSA for treating PHFs presenting with a head-split fracture in an elderly patient (94%), pre-existing rotator cuff tear (84%), and pre-existing glenohumeral arthritis with an intact cuff (75%). Similarly, both groups preferred ORIF for PHFs in young patients with a fracture dislocation (94%). In contrast, although most trauma surgeons preferred to manage PHFs in low functioning patients with a significantly displaced fracture or nonreconstructable injury nonoperatively (84% and 86%, respectively), shoulder surgeons preferred either RSA (44% and 46%, respectively) or nonoperative treatment (54% and 49%, respectively) (P .001). Similarly, although trauma surgeons preferred to manage PHFs in young patients with a head-split fracture or limited humeral head subchondral bone with ORIF (98% and 87%, respectively), shoulder surgeons preferred either ORIF (54% and 62%, respectively) or HA (43% and 34%, respectively) (P .001).ORIF and HA are preferred for treating simple PHFs in young patients with good bone quality or fracture dislocations, whereas RSA and nonoperative management are preferred for complex fractures in elderly patients with poor bone quality, rotator cuff dysfunction, or osteoarthritis. The preferred management differed between shoulder and trauma surgeons for half of the common PHF presentations, highlighting the need for future research.

Silver nanomaterials (Ag NMs) have been used in a variety of commercial products to take advantage of their antimicrobial properties. However, there are concerns that these AgNMs can be released during/after use and enter wastewater streams, potentially impacting aquatic systems or accumulating in wastewater biosolids. Biosolids, which are a residual of wastewater treatment processes, have been found to contain AgNMs and are frequently used as agricultural fertilizer. Since the function of soil microbial communities is imperative to nutrient cycling and agricultural productivity, it is important to characterize and assess the effects that silver nanomaterials could have in agricultural soils. In this study agricultural soil was amended with pristine engineered (PVP-coated or uncoated AgNMs), aged silver (sulphidized or released from textiles) nanomaterials, and ionic silver to determine the fate and toxicity over the course of three months. Exposures were carried out at various environmentally relevant concentrations (1 and 10 mg Ag/kg soil) representing between 30 to over 800 years of equivalent biosolid loadings. Over thirteen different methodologies and measures were used throughout this study to assess for potential effects of the silver nanomaterials on soil, including microbial community composition, average well colour development (AWCD) and enzymatic activity. Overall, the AgNM exposures did not exhibit significant toxic effects to the soil microbial communities in terms of density, activity, function and diversity. However, the positive ionic silver treatment (100 mg Ag/kg soil) resulted in suppression to microbial activity while also resulting in significantly higher populations of Frankia alni (nitrogen-fixer) and Arenimonas malthae (phytopathogen) as compared to the negative control (p < 0.05, Tukey HSD) which warrants further investigation.

Background: The lateral extensile approach (LEA) is an operative approach for calcaneal fractures. High rates of wound complications have led to alternative approaches such as the sinus tarsi approach to grow in popularity. The LEA affords substantial visualization of the calcaneus. This visualization has never been compared in a quantitative manner with the sinus tarsi approach (STA). We aim to quantify the calcaneal visualization afforded by STA and LEA. Methods: Seven pair-matched, fresh-frozen, below-knee cadaver extremities were included. For each pair, one side received an LEA and the other side received an STA. Results: There were no statistically significant differences in the articular surfaces accessible between the 2 approaches. The total calcaneal surface area accessible was 3107.08 mm2 for LEA and 1444.19 mm2 for STA ( P = .02). The LEA allowed better exposure to the lateral wall ( P = .01) and the dorsal tuberosity of the calcaneus ( P = .04). Conclusion: The STA allows for equivalent articular surface exposure when compared with the LEA. Although LEA allows for greater exposure of the lateral wall and dorsal tuberosity, direct visualization of these structures may not warrant the higher risk of wound complications. Surgeons should consider these differences when choosing an operative approach in the treatment of calcaneal fractures. : Level III

Vascular injuries associated with fractures are limb-threatening injuries with notable morbidity. The prompt and thorough evaluation of these patients is imperative to diagnose vascular injuries, and coordinated multidisciplinary care is needed to provide optimal outcomes. The initial assessment includes a detailed physical examination assessing for hard and soft signs of arterial injury, and the arterial pressure index can be used to reliably identify vascular compromise and the need for additional assessment or intervention. Advanced imaging in the form of CT angiography is highly sensitive in additional characterization of the potential injury and can be obtained in an expedient manner. The optimal treatment of fractures with vascular injuries includes providing skeletal stability and confirming or reestablishing adequate distal perfusion as soon as possible. Options for vascular intervention include observation, ligation, direct arterial repair, vascular bypass grafting, endovascular intervention, and staged temporary shunting, followed by bypass grafting. Although the optimal sequence of surgical intervention remains an incompletely answered question, the orthopaedic role in the care of patients with these injuries is to provide mechanical stability to the injured limb to protect the vascular repair and surrounding soft-tissue envelope.

Nanotoxicology research commonly utilizes pristine nanomaterials for toxicity assessment, which may not be perfectly representative of what is released into environmental systems. The goal of the present study was to develop a method to simulate human weathering of silver-containing textiles. To achieve this goal the roles of physical and chemical stress on X-Static® containing athletic textiles were investigated and compared to data collected from human weathering experiments and literature. Chemical weathering methods (artificial sweat) were used independently and alongside physical weathering methods (3D printed stretching and abrasion instruments). Non-weathered control textiles were found to release 29 ± 11 mg Ag/kg of textile into wash water effluent (ICP-MS), with 16% being released as ionic silver (ICP-MS) and the rest as metallic nanomaterials, nanosheets, and particulates of varying size (SEM/XANES). Real and simulated human weathered textiles released similar amounts of total silver (67 ± 11 mg Ag/kg, 84 ± 13 mg Ag/kg respectively) with the silver released being composed of ionic (1.5%, 2%) and a mixture of metallic and chlorinated nanomaterials, nanosheets, and particulates. The method was shown to effectively detach environmentally representative silver materials from silver-containing textiles and can provide such materials for future studies on the assessment of their fate, transport, and toxicity.

This study explored smoldering combustion for remediating polyfluoroalkyl substance (PFAS)-impacted granular activated carbon (GAC) and PFAS-contaminated soil. GAC, both fresh and PFAS-loaded, was employed as the supplemental fuel supporting smoldering in mixtures with sand (≈175 mg PFAS/kg GAC-sand), with PFAS-spiked, laboratory-constructed soil (≈4 mg PFAS/kg soil), and with a PFAS-impacted field soil (≈0.2 mg PFAS/kg soil). The fate of PFAS and fluorine was quantified with soil and emission analyses, including targeted PFAS and suspect screening as well as hydrogen fluoride and total fluorine. Results demonstrated that exceeding 35 g GAC/kg soil resulted in self-sustained smoldering with temperatures exceeding 900 °C. Post-treatment PFAS concentrations of the treated soil were near (2 experiments) or below (7 experiments) detection limits (0.0004 mg/kg). Further, 44% of the initial PFAS on GAC underwent full destruction, compared to 16% of the PFAS on soil. Less than 1% of the initial PFAS contamination on GAC or soil was emitted as PFAS in the quantifiable analytical suite. Results suggest that the rest were emitted as altered, shorter-chain PFAS and volatile fluorinated compounds, which were scrubbed effectively with GAC. Total organic fluorine analysis proved useful for PFAS-loaded GAC in sand; however, analyzing soils suffered from interference from non-PFAS. Overall, this study demonstrated that smoldering has significant potential as an effective remediation technique for PFAS-impacted soils and PFAS-laden GAC.

Per- and polyfluoroalkyl substances (PFAS) are manmade, fluorinated organic chemicals which have been identified as persistent organic pollutants. PFAS have surface active properties that have made them suitable for applications in oil- and water-resistant products, as well as many firefighting foams. No on-site remediation strategies exist to treat PFAS impacted soils. Mechanochemical remediation of PFOS- and PFOA-amended sand via a planetary ball mill was studied. The effect of sand mass, KOH as a co-milling reagent, and water saturation on the degradation of PFOA and PFOS was evaluated. By 4 h of milling concentrations were reduced by up to 98% for PFOS-amended dry sand and 99% for PFOA-amended dry sand without the addition of a co-milling reagent. Water saturation was determined to be a significant hindrance on the mechanochemical destruction of PFOS and PFOA. A maximum of 89% of fluoride was recovered from PFOS-amended sand when KOH was used as a co-milling reagent. It is hypothesized that reactive particles generated from the fracture of sand grains react with PFAS molecules to initiate destruction, which can result in full defluorination. Milling experiments were also conducted on soils from a Canadian firefighting training area (FFTA), demonstrating that PFOS concentrations can be reduced by up to 96% in site soils. For the first time, ball milling for the remediation of PFAS in environmental media has been demonstrated using amended sand and legacy soils from a FFTA.

Diffusion of perfluorooctanoate (PFOA) and perfluorooctane sulfonate (PFOS) through 0.1 mm and 0.75 mm LLDPE and 0.1 mm and 0.75 mm LLDPE coextruded with ethyl vinyl alcohol (denoted as CoEx) at room temperature (23 °C), 35 °C, and 50 °C is examined. These tests had negligible source depletion throughout the monitoring period, indicating limited contaminant partitioning and diffusion through the LLDPE. At 483 days, 23 °C receptor PFOA and PFOS concentrations, cr, were

We collected over 40 groundwater samples from a per- and polyfluoroalkyl substances (PFAS) impacted legacy fire fighting training area in Canada to develop an in-depth assessment of the relationship between PFAS and in situ microbial communities. Results suggest differential transport of PFAS of differing chain-length and head group. There is also evidence of PFAS degradation, in particular 6:2 FTS degradation. Although PFAS constituents were not major drivers of microbial community structure, the relative abundance of over one hundred individual genera were significantly associated with PFAS chemistry. For example, lineages within the Oxalobacteraceae family had strong negative correlations with PFAS, whilst the Desulfococcus genus has strong positive correlations. Results also suggest a range of genera may have been stimulated at low to mid-range concentrations (e.g., Gordonia and Acidimicrobium), with some genera potentially inhibited at high PFAS concentrations. Any correlations identified need to be further investigated to determine the underlying reasons for observed associations as this is an open field site with the potential for many confounding factors. Positive correlations may ultimately provide important insights related to development of biodegradation technologies for PFAS impacted sites, while negative correlations further improve our understanding of the potential negative effects of PFAS on ecosystem health.