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Purpose: While decreased time to fixation in femur fractures improves mortality, it remains unclear if the same relationship exists for pelvic fractures. The National Trauma Data Bank (NTDB) is a data repository for trauma hospitals in the United States (injury characteristics, perioperative data, procedures, 30-day complications), and we used this to investigate early, significant complications after pelvic-ring injuries., Methods: The NTDB (2015-2016) was queried to capture operative pelvic ring injuries in adult patients with injury severity score (ISS) ≥ 15. Complications included medical and surgical complications, as well as 30-day mortality. Multivariable logistic regression was used to investigate the association between days to procedure and complications after adjusting for demographic characteristics and comorbidities., Results: 2325 patients met inclusion criteria. 532 (23.0%) sustained complications, and 72 (3.2%) died within the first 30 days. The most common complications were deep vein thrombosis (DVT) (5.7%), acute kidney injury (AKI) (4.6%), and unplanned intensive care unit (ICU) admission (4.4%). In a multivariate analysis, days to procedure was independently significantly associated with complications, with an adjusted odds ratio (95% confidence interval) of 1.06 (1.03-1.09, P < 0.001), best interpreted as a 6% increase in the odds of complication or death for each additional day., Conclusion: Time to pelvic fixation is a significant and modifiable risk factor for major complications and death. This suggests we should prioritize time to pelvic fixation on trauma patients to minimize mortality and major complications., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: The purpose of this study was to characterize the relationship between a novel radiographic measurement on initial AP pelvis radiograph (termed "bladder shift," BS) to intraoperative blood loss (IBL) during acetabular surgical fixation., Methods: All adult patients receiving unilateral acetabular fixation (Level 1 academic trauma; 2008-18) were reviewed. AP pelvis radiographs were reviewed for visible bladder outlines and then measured to determine the percentage deformation toward the midline. Hemoglobin & hematocrit data were then used to calculate quantitative blood loss between pre- and post- operative blood counts for data analysis., Results: 371 patients with unilateral traumatic acetabular fractures requiring fixation were reviewed; 99 of these had visible bladder outlines, complete blood count and transfusion data (2008-2018; 66% associated patterns). Median bladder shift (BS) was 13.3%. Every 10% of bladder shift was associated with 123 mL greater IBL. Patients with full bladder shift to midline sustained a median 1.5L IBL (interquartile range [IQR] 0.8 to 1.6). Associated patterns had a threefold greater median BS (associated: 16.5% [15.4 to 45.9] vs. elementary: 5.6% [1.1 to 15.4], p < 0.05) and received intraoperative pRBC twice as frequently (57% vs. 24%, p < 0.01)., Conclusions: Radiographic bladder shift is an easily available visual marker, in patients sustaining acetabular fractures, that may predict intraoperative hemorrhage and need for transfusions., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Objective: To determine whether there is a threshold of elevated hemoglobin A1C (HbA1c) above which the complication risk is so high that fracture fixation should be avoided., Design: Retrospective cohort study., Setting: Academic Level I trauma center., Patients/participants: A cohort of 187 patients with HbA1c values >7 and operatively treated extremity fractures., Intervention: Surgical fixation of extremity fractures., Main Outcome Measurements: Rate of major orthopaedic complication (loss of reduction, nonunion, infection, and need for salvage procedure)., Results: 34.8% demonstrated HbA1c > 9% and 12.3% with HbA1c > 11. Major complications occurred in 31.4%; HbA1c values were not predictive. We found no evidence of a clinically or statistically significant relationship between HbA1c and risk of major complication. The odds ratio for a one-point increase in HbA1c was 1.006 ( P = 0.9439), and the area under the receiver operating characteristic curve, which reflects the average probability that someone with a major complication will have a higher HbA1c than someone without, was 0.51 (95% confidence interval 0.42-0.61), equivalent to random chance., Conclusion: Diabetic patients with fracture demonstrated an extremely high overall rate of complications, with 30.5% experiencing a major complication. However, patients with extreme diabetic neglect did not have higher complication rates after extremity fracture fixation when compared with patients with controlled and uncontrolled diabetes. There was no correlation between rate of complication and level of HbA1c. In addition, there was no difference in complication rate between upper and lower extremity fractures or between fractures treated with open or percutaneous fixation. This suggests that fracture treatment decision-making should not be altered for patients with poor diabetic control, and that surgery is not contraindicated in patients with an extremely high HbA1c., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To assess the utility of outpatient postmobilization radiographs in the nonoperative treatment of lateral compression type I (LC1) (OTA/AO 61-B1) pelvic ring injuries., Design: Retrospective series., Setting: Academic, Level 1 trauma center, 2008-2018., Patients/participants: A series of 173 patients with nonoperatively treated LC1 pelvic ring injuries was identified. Of these, 139 received a complete set of outpatient pelvic radiographs with which to assess displacement., Intervention: Outpatient pelvic radiographs to assess additional fracture displacement and potential need for surgical intervention., Main Outcome Measurements: Rate of conversion to late operative intervention based on radiographic displacement., Results: No patient in this cohort received late operative intervention. A majority of the patients sustained incomplete sacral fractures (82.6%) and unilateral rami fractures (75.1%), and 92.8% demonstrated less than 10 mm of displacement on their final radiographs., Conclusions: There is a low utility of repeat outpatient radiographs of stable, nonoperative LC1 pelvic ring injuries as they do not undergo late displacement., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Evaluate the species distribution and resistance patterns of bacterial pathogens causing surgical site infection (SSI) after operative fracture repair, with and without the use of intrawound powdered antibiotic (IPA) prophylaxis during the index surgery., Design: Retrospective cohort study., Setting: Academic, level 1 trauma center, 2018-2020., Patients/participants: Fifty-nine deep SSIs were identified in a sample of 734 patients with 846 fractures (IPA [n = 320], control [n = 526]; open [n = 157], closed fractures [n = 689]) who underwent orthopaedic fracture care. Among SSIs, 28 (48%) patients received IPA prophylaxis and 25 (42%) of the fractures were open., Intervention: Intrawound powdered vancomycin and tobramycin., Main Outcome Measurements: Distribution of bacterial species and resistance patterns causing deep surgical site infections requiring operative debridement., Results: Zero patients developed infections caused by resistant strains of streptococci, enterococci, gram-negative enterics, Pseudomonas , or Cutibacterium species. The only resistant strains isolated were methicillin resistance (19%) and oxacillin-resistant coagulase-negative staphylococci (16%). There was no associated statistical difference in the proportion of bacterial species isolated, their resistance profiles, or rate of polymicrobial infections between the IPA and control group. Most (93%) cases using IPAs included vancomycin and tobramycin powders. There were 59 SSIs; 28 (9%) in the IPA cohort and 31 (6%) in the control cohort ( P = 0.13)., Conclusion: The use of local antibiotic prophylaxis resulted in no measurable increase in the proportion of infections caused by resistant bacterial pathogens after operative treatment of fractures. However, the small sample size and limited time frame of these preliminary data require continued investigation into their role as an adjunct to SSI prophylaxis., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

»: A transgender person is defined as one whose gender identity is incongruent with their biological sex assigned at birth. This highly marginalized population numbers over 1.4 million individuals in the U.S.; this prevalence skews more heavily toward younger generations and is expected to increase considerably in the future., »: Gender-affirming hormone therapy (GAHT) has physiologic effects on numerous aspects of the patient's health that are pertinent to the orthopaedic surgeon, including bone health, fracture risk, and perioperative risks such as venous thromboembolism and infection., »: Language and accurate pronoun usage toward transgender patients can have a profound effect on a patient's experience and on both objective and subjective outcomes., »: Gaps in research concerning orthopaedic care of the transgender patient are substantial. Specific areas for further study include the effects of GAHT on fracture risk and healing, outcome disparities and care access across multiple subspecialties, and establishment of perioperative management guidelines., Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G201)., (Copyright © 2020 by The Journal of Bone and Joint Surgery, Incorporated.)

The fragility index (FI) is a powerful tool that can be used to assess the statistical strength of a study outcome. This metric is defined as the number of patients who would need to have an alternative outcome to convert a clinical trial result from statistically significant to not statistically significant, or vice versa. No studies to date have used the FI to evaluate surgical and procedural clinical trials in the orthopaedic oncology literature. The primary purpose of this study was to use the FI to evaluate the statistical strength of widely cited surgical and procedural clinical trials in orthopaedic oncology., Methods: We performed a PubMed search for orthopaedic oncology clinical trials in high impact orthopaedics-focused, oncology-focused, and general medicine journals. For each study included in this analysis, we calculated the FI for all identified dichotomous, categorical outcomes., Results: We identified 23 studies with 48 outcomes. Twelve of these outcomes were statistically significant, with a median FI of two. Nine studies addressed the number of patients lost to follow up, and the FI was less than the number of patients lost to follow up for most outcomes (60%) in these studies., Conclusions: The orthopaedic oncology literature has substantial statistical fragility, likely explained by a high number of patients lost to follow up and small sample sizes. More multicenter, cooperative studies are necessary to increases the robustness of clinical research in orthopaedic oncology., Competing Interests: Dr. Tyler or or an immediate family member has stock or stock options held in Tiathera Co., on the Executive Board of J. R. Gladden Society and serves as a board member, owner, officer, or committee member of Medical Board of Trustees, Musculoskeletal Transplant Foundation. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Forrester, Dr. Jang, Ms. Lawson, and Ms. Capi., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Introduction: There is considerable variation in brain death understanding and policies between medical institutions, however, studies have not yet compared different health-care professionals working in the same hospital., Research Questions: The overall aim of this study was to evaluate understanding of brain death among health-care professionals within intensive care units (ICUs) at a single institution., Design: Study participants included 217 attending physicians, residents, nurses, medical students, and other ICU team members in 6 ICUs. Participants completed a 21-question survey pertaining to knowledge of brain death and related institutional policies as well as opinions about brain death., Results: We found a wide range of brain death understanding among health-care professionals in ICUs. Attending physicians have the greatest understanding (94.7%), followed by nurses (72.4%). In contrast, approximately half of the students and residents do not have a basic understanding of brain death. Brain death understanding was correlated to health-care role, years of experience, and whether the participant had formal training in brain death. Although most participants had been involved in cases of brain death, a much smaller number had received formal training on death by neurological criteria., Discussion: The present study observed a paucity of clinical training in brain death among health-care professionals in the study ICUs. There is an opportunity for improved clinical education on brain death that could improve communication with families about brain death and potentially increase the number of organs transplanted.

We present evidence for nuclear spin-lattice relaxation driven by glassy nematic fluctuations in isovalent P-doped BaFe&#95;{2}As&#95;{2} single crystals. Both the ^{75}As and ^{31}P sites exhibit a stretched-exponential relaxation similar to the electron-doped systems. By comparing the hyperfine fields and the relaxation rates at these sites we find that the As relaxation cannot be explained solely in terms of magnetic spin fluctuations. We demonstrate that nematic fluctuations couple to the As nuclear quadrupolar moment and can explain the excess relaxation. These results suggest that glassy nematic dynamics are a common phenomenon in the iron-based superconductors.

We present 75As nuclear magnetic resonance data from measurements of a series of Ba(Fe(1-x)Co(x))2As2 crystals with 0.00≤x≤0.075 that reveals the coexistence of frozen antiferromagnetic domains and superconductivity for 0.060≤x≤0.071. Although bulk probes reveal no long range antiferromagnetic order beyond x=0.06, we find that the local spin dynamics reveal no qualitative change across this transition. The characteristic domain sizes vary by more than an order of magnitude, reaching a maximum variation at x=0.06. This inhomogeneous glassy dynamics may be an intrinsic response to the competition between superconductivity and antiferromagnetism in this system.

Background: Anti-TNF-alpha agents have been shown to be effective for the induction of remission in Crohn's disease. The role of TNF-alpha blocking agents in ulcerative colitis is, however, unclear and recent studies have yielded conflicting results., Objectives: To evaluate the efficacy of TNF-alpha antibody for induction of remission in ulcerative colitis, and to determine adverse events associated with TNF-alpha antibody treatment., Search Strategy: We searched MEDLINE (1966 to 2005), EMBASE (1984 to 2005), the Cochrane Central Register of Controlled Trials (Issue 3, 2004) and the IBD/FBD Review Group Specialized Trials Register. We hand-searched the articles cited in each publication., Selection Criteria: Only randomised controlled trials in which patients with active ulcerative colitis (defined by a combination of clinical, radiographic, endoscopic and histologic criteria) were randomly allocated to receive a TNF-alpha blocking agent in the treatment arm, and to receive placebo or another treatment in the comparison arm were included., Data Collection and Analysis: Data extraction and assessment of methodological quality of each study were independently performed by two reviewers. Any disagreement among reviewers was resolved by consensus. The main outcome measure was the occurrence of remission as defined by the primary studies. Other endpoints were clinical, histological or endoscopic improvement as defined by the primary studies; improvement in quality of life as measured by a validated quality of life tool and the occurrence of adverse events., Main Results: Seven randomised controlled trials were identified that satisfied the inclusion criteria. In patients with moderate to severe ulcerative colitis whose disease was refractory to conventional treatment using corticosteroids and/or immunosuppressive agents, infliximab (three intravenous infusions at 0, 2, and 6 weeks) was more effective than placebo in inducing clinical remission (Relative Risk (RR) 3.22, 95% CI 2.18 to 4.76); inducing endoscopic remission (RR 1.88, 95% CI 1.54 to 2.28); and in inducing clinical response (RR 1.99, 95% CI 1.65 to 2.41) at 8 weeks. A single infusion of infliximab was also more effective than placebo in reducing the need for colectomy within 90 days after infusion (RR 0.44, 95% CI 0.22 to 0.87)., Authors' Conclusions: In patients with moderate to severe ulcerative colitis whose disease is refractory to conventional treatment using corticosteroids and/or immunosuppressive agents, infliximab is effective in inducing clinical remission, inducing clinical response, promoting mucosal healing, and reducing the need for colectomy at least in the short term. Serious adverse events attributable to infliximab were not common in the included studies but physicians should be aware of and be prepared to deal with potential adverse events such as anaphylactic reactions and infections.