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Orthopaedic procedures can affect patients' ability to perform activities of daily living, such as driving automobiles or other vehicles that require coordinated use of the upper and lower extremities. Many variables affect the time needed before a patient can drive competently after undergoing orthopaedic surgery to the extremities. These variables include whether the patient underwent upper or lower extremity surgery, the country in which the patient resides, whether the right or left lower extremity is involved, whether the dominant arm is involved, whether the extremity is in a cast or brace, whether the patient has adequate strength to control the steering wheel, and whether the patient is taking pain medication. The type and complexity of the procedure also influence the speed of return of driving ability. Few studies provide definitive data on driving ability after upper or lower extremity surgery. Patients should be counseled not to drive until they can control the steering wheel and the pedals competently and can drive well enough to prevent further harm to themselves or to others. This review discusses the limited recommendations in the literature regarding driving motorized vehicles after upper or lower extremity orthopaedic surgery.

Optimal cephalomedullary nail (CMN) length for unstable pertrochanteric femur fractures is controversial. Long CMNs (L-CMNs) are currently recommended; however, intermediate-length CMNs (I-CMNs) may provide stable fixation without the additional surgical steps required by L-CMNs. We analyzed outcomes after unstable pertrochanteric femur fractures treated with L-CMNs or I-CMNs to determine whether functional outcomes, perioperative measures, complications, and mortality and reoperation rates differ by CMN length.We retrospectively reviewed medical records at our institution for 100 patients who received surgical treatment for pertrochanteric femur fractures from June 2014 to June 2016. Data from 43 unstable pertrochanteric femur fractures treated with L-CMNs (n = 25) or I-CMNs (n = 18) were analyzed. We evaluated operative time, fluoroscopy time, intraoperative blood loss, blood transfusions, and perioperative complications; peri-implant fracture, malunion, reoperation, and death; and neck-shaft angle, tip-apex distance, and 6-month postoperative functional scores. We analyzed categorical data with Fisher exact tests and continuous data with Student t tests. P 0.05 was considered significant.The I-CMN group had shorter operative time (68 versus 92 min; P = 0.048), shorter fluoroscopy time (72 versus 110 s; P = 0.019), and less intraoperative blood loss (80 versus 168 mL; P 0.001) than the L-CMN group. The groups were similar in rates of blood transfusion, perioperative complications, peri-implant fracture, malunion, reoperation, and death. Six-month postoperative functional scores were similar between groups (P 0.05).We found operative advantages of I-CMNs over L-CMNs with no difference in treatment outcomes.Level IV, Retrospective case series study.

The estimated prevalence of von Willebrand’s disease (vWD) worldwide has been widely reported as near 1%. This makes vWD the most common inherited bleeding disorder. Although the condition can present with varying degrees of severity, it is usually mild and its presence often goes undiagnosed until significant hemorrhagic stress is placed on the patient, such as during major orthopedic surgical procedures. Given the heightened prevalence of the disorder in the general population, it is very important for all surgeons to be aware of its presentation, treatment options, and the side effects of these treatments in order to effectively reduce hemorrhagic and other medical complications related to vWD. von Willebrand’s disease is categorized as a disorder of primary hemostasis involving platelet dysfunction and the inability to produce sufficient plasma concentrations of von Willebrand factor (vWF). It is also associated with qualitative deficits in the structure of vWF which prevents normal function during the clotting cascade. Normal levels and structure of vWF act not only to initiate primary hemostasis but also to stabilize factor VIII. In more clinically significant cases of vWD, recombinant factor VIII protein may be needed in addition to replacement vWF to address all deficiencies in both primary and secondary hemostases [3]. There are three major pharmacologic treatment modalities available to address the clinically significant bleeding risks of vWD. They include the following: vWF/factor VIII replacement (Humate-P*), DDAVP (desmopressin), and antifibrinolytic treatment using estrogen-progesterone hormone therapy [4]. All therapies are associated with their own benefits and possible side effects. DDAVP carries no risk of transmitting infection or immunologic complications, is relatively inexpensive, and should be the preferred prophylactic treatment when possible. The drug acts by increasing endogenous release of vWF from circulating platelets. This maximizes all available circulatory system vWF into the plasma. One of the most significant potential side effects of desmopressin is severe water intoxication and concomitant hyponatremia. This unwanted effect may trigger severe physiologic consequences including seizure and death [6]. The drug acts as a synthetic form of anti-diuretic hormone (ADH), increasing the number of aquaporin channels in the collecting duct of the renal nephron, resulting in heightened free-water absorption, decreased urine output, and potential serum electrolyte dilution. This can become especially true if a patient’s fluid intake is not carefully observed. Excess free-water ingestion should be limited while on DDAVP, and IV fluid use meticulously scrutinized to ensure serum electrolyte concentrations remain at physiologic levels. If IV fluids are necessary, normal saline is preferred over lactated ringers due to its higher concentration of sodium per unit volume which should decrease the potential for DDAVP-induced hyponatremia. Despite the increased susceptibility and association with hyponatremia in the vWD pediatric population [4], the phenomenon can also present suddenly in the adult surgical patient as this case study demonstrates.

Background Earthquakes in developing countries are devastating events. Orthopaedic surgeons play a key role in treating earthquake-related injuries to the extremities. We describe orthopaedic injury epidemiology to help guide response planning for earthquake-related disasters. Methods Several databases were searched for articles reporting primary injury after major earthquakes from 1970 to June 2016. We used the following key words: “earthquake” AND “fracture” AND “injury” AND “orthopedic” AND “treatment” AND “epidemiology.” The initial search returned 528 articles with 253 excluded duplicates. The remaining 275 articles were screened using inclusion criteria, of which the main one was the description of precise anatomic location of fracture. This yielded 17 articles from which we analyzed the ratio of orthopaedic to nonorthopaedic injuries; orthopaedic injury location, type, and frequency; fracture injury characteristics (open vs. closed, single vs. multiple, and simple vs. comminuted); and first-line treatments. Results Most injuries requiring treatment after earthquakes (87%) were orthopaedic in nature. Nearly two-thirds of these injuries (65%) were fractures. The most common fracture locations were the tibia/fibula (27%), femur (17%), and foot/ankle (16%). Forty-two percent were multiple fractures, 22% were open, and 16% were comminuted. The most common treatment for orthopaedic injuries in the setting of earthquakes was debridement (33%). Conclusions Orthopaedic surgeons play a critical role after earthquake disasters in the developing world. A strong understanding of orthopaedic injury epidemiology and treatment is critical to providing effective preparation and assistance in future earthquake disasters.

Background:. The impact of left-handedness on orthopaedic surgeons and trainees has not been well described. We investigated the prevalence and perceived impact of left-handedness among orthopaedic surgeons and trainees. Methods:. We distributed a survey regarding handedness to active members of the American Orthopaedic Association and the Council of Orthopaedic Residency Directors affiliates, including department chairs, program directors, and residency and fellowship program coordinators. Program coordinators were asked to distribute the survey to their current residents and fellows. Results:. Of 510 survey respondents, 78 (15%) were identified as left hand dominant (LHD). Regarding scalpel/cautery use, 64% of LHD respondents reported using their left hand primarily and 10% reported using their right hand primarily; 26% of LHD respondents described themselves as ambidextrous in scalpel/cautery use, compared with 4.7% of right hand dominant (RHD) respondents (p < 0.001). Regarding suturing, 53% of LHD respondents reported using their left hand primarily and 38% reported using their right hand primarily; 9.0% of LHD respondents described themselves as ambidextrous when suturing, compared with 1.9% of RHD respondents (p = 0.012). Only 5.1% of LHD respondents reported having received laterality-specific psychomotor training, whereas 17% perceived a need for such training during residency; RHD respondents reported similar rates. Ambidexterity in scalpel/cautery use or suturing among LHD respondents was not associated with the perception that their left-handedness was advantageous. LHD attending surgeons were more likely than LHD trainees to perceive their handedness as advantageous (p = 0.007). Conclusions:. Fifteen percent of orthopaedic surgeons and trainees who responded to our survey were LHD. LHD respondents reported significantly higher rates of ambidexterity in both scalpel/cautery use and suturing compared with RHD respondents. Ambidexterity was not associated with a self-perception that left-handedness was advantageous. LHD-attending surgeons were significantly more likely than LHD residents/fellows to perceive their left-handedness as advantageous. There may be benefits to pairing LHD residents with LHD faculty surgeons early in their training to provide mentorship and insight regarding performing surgical procedures left handed. Level of Evidence:. Level IV.