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Quiescence is a prolonged but reversible state of cell-cycle arrest that is an adaptive feature of most adult stem cell populations. In the brain, quiescence helps to protect adult neural stem cells from stress and supports lifelong neurogenesis. Unfortunately however, entry into a quiescent or a slow-cycling state is also a malignant feature of brain cancer stem cells. In glioblastoma, where the process has been best characterised, quiescent glioma stem cells preferentially survive chemoradiation, and after therapy, reactivate to regrow the tumour and drive recurrence. In this Review, we discuss the in vitro and in vivo models that have been developed for studying neural stem cell quiescence and how these tools may be used to deepen biological understanding and to develop novel therapies targeting quiescent glioma stem cells., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objectives: The goal of this trial was to determine whether coronal plane angulation affects functional and clinical outcomes after the fixation of distal femur fractures., Design: Multicenter, randomized controlled trial SETTING: 20 academic trauma centers PATIENTS/PARTICIPANTS: 156 patients with distal femur fractures were enrolled. 123 patients were followed 12 months. There was clinical outcome data available for 105 patients at 3 months, 95 patients at 6 months and 81 patients at one year., Intervention: Lateral locked plating or retrograde intramedullary nailing MAIN OUTCOME MEASUREMENTS: Radiographic alignment, functional scoring including SMFA, Bother Index, and EQ-5D. Clinical scoring of walking ability, need for ambulatory support and ability to manage stairs., Results: At 3 months, there was no difference between groups (varus, neutral or valgus) with respect to any of the clinical functional outcome scores measured. At 6 months, compared to those with neutral alignment, patients with varus angulation had a worse Stair Climbing score (4.33 vs. 2.91, p = 0.05). At 12 months, the average patient with neutral or valgus alignment needed less ambulatory support than the average patient in varus. Walking distance ability was no different between the groups at any time point. With respect to the validated patient-based outcome scores, we found no statistical difference in in the SMFA, Bother, or EQ-5D between patients with valgus or varus mal-alignment and those with neutral alignment at any time point (p > 0.05). Regardless of coronal angulation, the SMFA trended towards lower (improved) scores over time, while EQ-5D scores for patients with varus angulation did not improve over time., Conclusions: Valgus angulation and neutral angulation may be better tolerated in terms of clinical outcomes like stair climbing and need for ambulatory support than varus angulation, though patient reported outcome measures like the SMFA, Bother Index and EQ-5D show no statistical significance. Most patients with distal femur fractures tend to improve during the first year after injury but many remain significantly affected at 12 months post injury., Competing Interests: Declaration of competing interest Dr. Tornetta receives royalty IP payments from and has pending and issued intellectual property with Smith & Nephew, owns stock or stock options in 4 Web, and publishing royalties with WK. For the remaining authors none were declared., (Copyright © 2024. Published by Elsevier Ltd.)

Background: Total hip arthroplasty (THA) for the treatment of acute acetabular fractures may be indicated where there is high risk for failure of open reduction and internal fixation. This study aimed to determine risks of revision and rates of major complications of THA for acute acetabular fractures., Methods: A retrospective review was performed (all-claims data files of a large national database) by querying International Classification of Disease, 10th revision procedure codes for THA within 14 days of acetabular fracture. We identified all-cause revision and surgical complications including dislocations, mechanical failures (loosenings or broken prostheses), infections, as well as medical complications. Demographic data collected included age, sex, obesity, and Charlson Comorbidity Index (CCI). Multivariate analyses evaluated the association of revision and major surgical complications after adjusting for demographic characteristics and comorbidities. We identified 956 THAs for the treatment of acute acetabular fracture from 2015 to 2020. Of all acute acetabular fractures treated with THA, 241 were concomitant with open reduction and internal fixation (ORIF), and 715 were THA-alone., Results: All-cause revision risk was 18.2%, overall major surgical complication rate 26.9%, and medical complication rate was 13.2%. Women were associated with increased risk of revision (adjusted odds ratio (aOR) 1.8; confidence interval (CI) 1.3 to 2.6, P = .001), dislocation (aOR 2.0; CI 1.5 to 3.1, P < .001), mechanical complication (aOR 2.1; CI 1.4 to 3.2, P < .001), and infection (aOR 1.6; CI 1.0 to 2.5, P = .044)., Conclusion: We noted risk of all-cause revision of 18.2%, overall major surgical complication rate of 26.9%, and overall major medical complication rate of 13.2% for THA as the treatment of acute acetabular fracture. We caution against broad expansion of THA for treatment of acute acetabular fractures. Furthermore, increased risks of revision and complications in women warrant additional investigation into patient and fracture characteristics that may contribute to this finding., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to identify the patient, injury, and treatment factors associated with infection of bicondylar plateau fractures and to evaluate whether center variation exists., Design: Retrospective review., Setting: Eighteen academic trauma centers., Patients/participants: A total of 1,287 patients with 1,297 OTA type 41-C bicondylar tibia plateau fractures who underwent open reduction and internal fixation were included. Exclusion criteria were follow-up less than 120 days, insufficient documentation, and definitive treatment only with external fixation., Intervention: Open reduction and internal fixation., Main Outcome Measurements: Superficial and deep infection., Results: One hundred one patients (7.8%) developed an infection. In multivariate regression analysis, diabetes (DM) (OR [odds ratio] 3.24; P ≤ 0.001), alcohol abuse (EtOH) (OR 1.8; P = 0.040), dual plating (OR 1.8; P ≤ 0.001), and temporary external fixation (OR 2.07; P = 0.013) were associated with infection. In a risk-adjusted model, we found center variation in infection rates (P = 0.030)., Discussion: In a large series of patients undergoing open reduction and internal fixation of bicondylar plateau fractures, the infection rate was 7.8%. Infection was associated with DM, EtOH, combined dual plating, and temporary external fixation. Center expertise may also play a role because one center had a statistically lower rate and two trended toward higher rates after adjusting for confounders., Level of Evidence: Level IV-Therapeutic retrospective cohort study., (Copyright © 2022 by the American Academy of Orthopaedic Surgeons.)

Blue Carbon Ecosystems (BCEs) help mitigate and adapt to climate change but their integration into policy, such as Nationally Determined Contributions (NDCs), remains underdeveloped. Most BCE conservation requires community engagement, hence community-scale projects must be nested within the implementation of NDCs without compromising livelihoods or social justice. Thirty-three experts, drawn from academia, project development and policy, each developed ten key questions for consideration on how to achieve this. These questions were distilled into ten themes, ranked in order of importance, giving three broad categories of people, policy & finance, and science & technology. Critical considerations for success include the need for genuine participation by communities, inclusive project governance, integration of local work into national policies and practices, sustaining livelihoods and income (for example through the voluntary carbon market and/or national Payment for Ecosystem Services and other types of financial compensation schemes) and simplification of carbon accounting and verification methodologies to lower barriers to entry., (© 2022. The Author(s).)

Objectives: To report functional outcomes of unilateral sacral fractures treated both operatively and nonoperatively., Design: Prospective, multicenter, observational study., Setting: Sixteen Level 1 trauma centers., Patients/participants: Skeletally mature patients with unilateral zone 1 or 2 sacral fractures categorized as displaced nonoperative (DN), displaced operative (DO), nondisplaced nonoperative (NN), and nondisplaced operative (NO)., Main Outcome Measurements: Pelvic displacement was documented on injury plain radiographs. Short Musculoskeletal Function Assessment (SMFA) scores were obtained at baseline and at 3, 6, 12, and 24 months after injury. Displacement was defined as greater than 5 mm in any plane at the time of injury., Results: Two hundred eighty-six patients with unilateral sacral fractures were initially enrolled, with a mean age of 40 years and mean injury severity score of 16. One hundred twenty-three patients completed the 2-year follow-up as follows: 29 DN, 30 DO, 47 NN, and 17 NO with 56% loss to follow-up at 2 years. Highest dysfunction was seen at 3 months for all groups with mean SMFA dysfunction scores: 25 DN, 28 DO, 27 NN, and 31 NO. The mean SMFA scores at 2 years for all groups were 13 DN, 12 DO, 17 NN, and 17 NO., Conclusions: All groups (operative/nonoperative and displaced/nondisplaced) reported worst function 3 months after injury, and all but (DN) continued to recover for 2 years after injury, with peak recovery for DN seen at 1 year. No functional benefit was seen with operative intervention for either displaced or nondisplaced injuries at any time point., Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Cases: Intraosseous (IO) access is an effective surrogate for intravascular access in critically ill patients. We present 2 cases of IO complications. The first patient is a 44-year-old man with deep peroneal nerve sensorimotor dysfunction due to possible missed acute compartment syndrome from improper placement of a tibial IO needle. The second patient is an immunosuppressed 69-year-old man with idiopathic factor VIII deficiency who required amputation 7 months after right tibia IO access., Conclusion: These adverse events of IO access are limited in the literature. We make recommendations to reduce these outcomes., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B322)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Objective: While orthopedic residency training varies among programs, an inevitable phenomenon is a transition for interns from consistent oversight to independent call with indirect supervision. It is therefore crucial to reliably assess trainees' ability to perform basic procedures. The objective of the study was to evaluate the utility of a novel Orthopaedic Intern Skills Assessment (OISA) to assess skill level., Design: In a cohort study, participants were evaluated on their ability to complete eleven skills in a simulated environment. Using a standardized patient and/or cadaveric specimen, we assessed skeletal traction, joint aspiration, joint injection, laceration repair, ankle brachial index measurement, compartment pressure monitoring, upper and lower extremity splinting, informed consent, spine trauma exam, and cervical spine clearance abilities., Setting: The assessment took place in a medical simulation lab at the Oregon Health & Science University in Portland, Oregon., Participants: Third- or fourth-year medical students interested in orthopedics, incoming interns (preinterns), and residents within 1 month of completing their intern year (postinterns) were invited to participate in the study. All interested individuals were included. Of the 20 individuals contacted, 14 (70%) consented: 4 medical students (40%), 5 preinterns (100%), and 5 postinterns (100%). All consenting individuals finished their participation in the research., Results: Postintern skill completion rate was significantly higher than preinterns (p = 0.006) and medical students (p < 0.001). Completion rates for preinterns were also significantly higher rate than medical students (p = 0.035)., Conclusions: Our OISA found that postinterns had reached a basic orthopedic skill level expected of a junior resident without in-house supervision. Our OISA also highlighted areas of training that needed further attention, which will help orthopedic training programs verify an appropriate level of skill as trainees' progress from a supervised intern year to taking indirectly supervised junior resident call, and help identify areas where increased training is needed., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Pelvic fractures are diverse injuries with varying degrees of severity. Treatment recommendations are determined by the associated instability. For likely stable patterns, postmobilization imaging is used to assess for occult instability. This study assesses the utility of postmobilization images and determines how often they alter the recommendations for treatment., Methods: Records at a single level 1 trauma center from January 2007 through December 2014 were reviewed, and patients with Current Procedural Terminology codes and International Classification of Diseases, Ninth Revision codes for pelvic and acetabular fractures were identified. For those chosen for nonsurgical treatment at presentation, a detailed chart review was performed to identify patients who had postmobilization radiographs and to determine whether this imaging led to a change in treatment recommendations., Results: Inclusion criteria were met by 762 patients whose average age was 50 years. Of 331 patients planned for nonsurgical treatment at presentation, 168 (51%) had postmobilization images. The postmobilization radiographs did not alter treatment recommendations in any of these patients; however, three of these patients underwent surgical stabilization based on the patients' report of pain with attempted mobilization., Discussion: Routine postmobilization imaging has limited value for patients with pelvic injuries and a low likelihood for instability, such as those with incomplete sacral fractures. Eliminating this step would reduce cost and decrease radiation exposure. The need for change in treatment plan or further imaging should be based on the patient's clinical progress with weight bearing., Level of Evidence: Level 4.

Objectives: To compare pain after operative versus nonoperative pelvic ring injuries with unilateral sacral fractures., Design: Prospective, multicenter, observational., Setting: Sixteen trauma centers., Patients/participants: Skeletally mature patients with pelvic ring injury and minimally displaced unilateral zone 1 or 2 sacral fractures and without anteroposterior compression injuries., Main Outcome Measurements: Pelvic displacement was documented on injury plain radiographs and computed tomography scans; a 10 point Visual Analog Scale (VAS) was used to evaluate pain was obtained in the anterior and posterior pelvic ring during the time of union (12 weeks)., Results: One hundred ninety-four patients with unilateral sacral fractures displaced less than 5 mm, mean age of 38.7, and mean Injury Severity Score of 14.5 were included. Ninety-nine percent had lateral compression injuries, and 62% were in zone 1. Seventy-four percent were treated nonoperatively. Nonoperative patients had more zone 1 fractures (71%, P = 0.004). Nonoperative patients reported mean VAS 2.7 points higher in the posterior pelvis (P = 0.01) and 1.9 points higher anteriorly (P = 0.11) 24 hours after injury compared with patients treated operatively. After 3 months, nonoperative patients reported higher VAS scores than operative patients: 4.0 versus 2.9 posteriorly (P = 0.019) and 3.2 versus 2.3 anteriorly (P = 0.035)., Conclusions: For sacrum fractures with minimal or no displacement, slight differences in the VAS were noted within 24 hours after injury or surgery, but limited differences were seen at 3 months for either operatively treated minimally or undisplaced sacrum fractures. It is unknown whether this represents clinical relevance. These differences were below the minimally important clinical difference for VAS scores for other orthopaedic conditions., Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The paper focuses on the identification of atypical fractures (AFFs). This paper examines the concordance between objective classification and expert subjective review. We believe the paper adds critical information about how to apply the American Society of Bone and Mineral Research (ASBMR) criteria to diagnose AFFs and is of high interest to the field., Introduction: Assess American Society of Bone and Mineral Research (ASBMR) criteria for identifying atypical femoral fractures (AFFs)., Methods: Two orthopedic surgeons independently evaluated radiographs of 372 fractures, applying ASBMR criteria. We assessed ease of applying ASBMR criteria and whether criteria-based assessment matched qualitative expert assessment., Results: There was up to 27% uncertainty about how to classify specific features. 84% of films were classified similarly for the presence of AFF according to ASBMR criteria; agreement increased to 94% after consensus meeting. Of 37 fractures categorized as AFFs based on ASBMR criteria, 23 (62.2%) were considered AFFs according to expert assessment (not relying on criteria). Only one (0.5%) femoral shaft fracture that did not meet ASBMR criteria was considered an AFF per expert assessment. The number of major ASBMR features present (four vs five) and whether there was periosteal or endosteal thickening ("beaking" or "flaring") played major roles in the discrepancies between ASBMR criteria-based and expert-based determinations., Conclusions: ASBMR AFF criteria were useful for reviewers but several features were difficult to interpret. Expert assessments did not agree with the ASBMR classification in almost one-third of cases, but rarely identified an AFF when a femoral shaft fracture did not meet ASBMR AFF criteria. Experts identified lateral cortical transverse fracture line and associated new-bone formation along with no or minimal comminution as crucial features necessary for the definition of atypical femoral fractures.

Background: Traumatic hip dislocations (THD) are a medical emergency. There is debate whether the painful reduction of a dislocated hip should be first attempted using primary conscious sedation (PCS) or primary general anesthesia (PGA) METHODS: All cases of native THD from 2006 to 2015 in the trauma registry of a level 1 trauma center were reviewed. The primary outcome was successful reduction of the THD., Results: 67 patients had a native, meaning not a hip prosthesis, THD. 34 (50.7%) patients had successful PCS, 12 (17.9%) failed PCS and underwent reduction following PGA. 21 (31.3%) underwent PGA. Patients in the PGA group were more severely injured. Time to reduction greater than 6 h was associated with PCS failure (Odds ratio (95% confidence interval) 19.75 (2.06,189.10) p = 0.01)., Conclusion: Clinicians treating patients with a THD can utilize either PCS or PGA with many patients safely reduced under PCS. However, patients whose hip have been dislocated for more than 6 h are at risk for failure with PCS, and are good candidates for PGA., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: To develop a model using wearable inertial sensors to assess the performance of orthopaedic residents while performing a diagnostic knee arthroscopy., Methods: Fourteen subjects performed a diagnostic arthroscopy on a cadaveric right knee. Participants were divided into novices (5 postgraduate year 3 residents), intermediates (5 postgraduate year 4 residents), and experts (4 faculty) based on experience. Arm movement data were collected by inertial measurement units (Opal sensors) by securing 2 sensors to each upper extremity (dorsal forearm and lateral arm) and 2 sensors to the trunk (sternum and lumbar spine). Kinematics of the elbow and shoulder joints were calculated from the inertial data by biomechanical modeling based on a sequence of links connected by joints. Range of motion required to complete the procedure was calculated for each group. Histograms were used to compare the distribution of joint positions for an expert, intermediate, and novice., Results: For both the right and left upper extremities, skill level corresponded well with shoulder abduction-adduction and elbow prono-supination. Novices required on average 17.2° more motion in the right shoulder abduction-adduction plane than experts to complete the diagnostic arthroscopy (P = .03). For right elbow prono-supination (probe hand), novices required on average 23.7° more motion than experts to complete the procedure (P = .03). Histogram data showed novices had markedly more variability in shoulder abduction-adduction and elbow prono-supination compared with the other groups., Conclusions: Our data show wearable inertial sensors can measure joint kinematics during diagnostic knee arthroscopy. Range-of-motion data in the shoulder and elbow correlated inversely with arthroscopic experience. Motion pattern-based analysis shows promise as a metric of resident skill acquisition and development in arthroscopy., Clinical Relevance: Wearable inertial sensors show promise as metrics of arthroscopic skill acquisition among residents., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)