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Orthopaedic trauma does not present in a linear fashion. Fluctuations in trauma volumes, after-hours surgery and surgical wait times impact orthopaedic surgeons and patients. There is little research focussing on how surgical trauma volumes change throughout the week. This study investigated the relationship between day of the week and surgical orthopaedic trauma volumes, after-hours surgery, and wait times for orthopaedic trauma patients.All unscheduled surgical orthopaedic trauma cases presenting to one level I and three level IV urban adult trauma centers between 2008 and 2018 were retrospectively reviewed. Fluctuations in orthopaedic trauma volumes and amount of after-hours surgeries completed were investigated using Multivariable Poisson regression. Fluctuations in patient wait times were investigated using linear regression.Weekends were associated with increased surgical wait times (8.9%, p0.001) despite decreased surgical trauma volumes (9.1%, p0.001). Surgical orthopaedic trauma volumes were elevated on weekdays and decreased on weekends. More after-hours surgeries were performed from Thursday to Saturday with most performed on Friday night (26.6%, p0.001). Surgical wait times increased midweek and remained high until Saturday.With a lack of dedicated trauma resources on the weekend, a significant increase in after-hours surgery and surgical wait times was identified following surgical volumes peaking on Thursday and Friday. We suggest adapting resource allocation to reflect surgical volumes. Dedicated weekend orthopaedic trauma resources or an adaptable schedule during increased orthopaedic trauma have the potential to ease this bottleneck, improve patient care, and decrease hospital costs.

To the Editor: Acute kidney injury (AKI) is a lesser-known complication of hip fracture that may come about owing to decreased kidney perfusion and heightened inflammation from trauma, pain, bleeding, and fasting. Approximately 15%-20% of patients undergoing surgery for a hip fracture develop AKI, with 0.5%-1.8% receiving dialysis. [...]

Objective The aim of the study is to survey hand surgeons' perspectives on telemedicine during the coronavirus disease 2019 (COVID-19) pandemic and intended applications after the pandemic. Methods Online surveys were sent to 285 Canadian and American surgeons in late April and early May 2020. Results Response rate was 63% (180)—84% (152) American and 16% (28) Canadian. Forty-three percent (76) of respondents were in private practice, 36% (64) academics, 13% (24) privademics, and 6% (12) hospital employed. The most common telemedicine platform was Zoom. During the pandemic, 42% of patient visits were conducted via telemedicine; however, 37% required a subsequent in-person office visit. The most common complaint by surgeons was the inability to provide routine in-office procedures. The most beneficial feature was ease of use, and the most frustrating feature was connectivity difficulty. Time spent was similar to in-person visits, and surgeons were likely to recommend their platforms. Surgeons were neutral about using telehealth in the future and were most likely to use it for follow-up visits. New patient visits for traumatic injuries or fractures were of limited value. Canadians used telemedicine for a greater proportion than Americans (50 vs. 40%, p Conclusion Telemedicine comprised nearly half of patient encounters during the COVID-19 pandemic, but limitations remain.

Management of chronic isolated scapholunate interosseous ligament (SLIL) injuries has generated a substantial volume of low-quality literature with descriptions of multiple new surgical techniques, and the impact of instability pattern and the optimal surgical technique remain unclear. The primary goal of this review was to compare clinical, radiographic and patient-rated outcomes between current surgical techniques.We performed a systematic literature search using multiple databases. We analyzed clinical, radiographic and patient-reported outcomes. We used a fixed-effects model weighted by sample size with combined outcomes estimated via least squares means with 95% confidence intervals. We also performed a subgroup analysis of static versus dynamic instability.We assessed 805 procedures from 37 study groups, with 429 procedures used in subgroup analysis. There were no statistically significant differences in outcomes between surgical techniques or in subgroup analysis. Overall, postoperative wrist flexion and pain scores decreased, and grip strength and patient-rated outcomes improved.Compared to overall preoperative values, modest improvements in pain score, grip strength and functional outcome scores were obtained from a range of reconstructive procedures performed for chronic isolated SLIL injuries. No significant differences could be ascertained between surgical techniques, potentially owing to the low quality of evidence and procedure heterogeneity. This study provides accurate preoperative reference values for future studies, highlights the controversial clinical impact of instability classification, and the need for higher-quality multicentre or collaborative trials to improve our understanding and management of this common injury.La prise en charge des blessures chroniques du ligament interosseux scapho-lunaire (LISL) a généré un volume substantiel d’articles de faible qualité où sont décrites plusieurs nouvelles techniques chirurgicales, mais l’impact du modèle d’instabilité et la technique chirurgicale optimale restent à clarifier. Le principal objectif de cette revue était de comparer les résultats cliniques, radiographiques et autodéclarés par les patients entre les diverses techniques chirurgicales actuelles.Nous avons procédé à une interrogation systématique de la littérature dans plusieurs bases de données. Nous avons analysé les résultats cliniques, radiographiques et autodéclarés par les patients. Nous avons utilisé un modèle à effets fixes pondéré par la taille de l’échantillon, avec paramètres mixtes estimés par les moyennes des moindres carrés et des intervalles de confiance à 95 %. Nous avons aussi effectué une analyse de sous-groupes (instabilité radiographique dynamique c. statique).Nous avons évalué 805 interventions dans 37 groupes étudiés, et 429 interventions ont été utilisées dans les analyses de sous-groupes. On n’a noté aucune différence statistiquement significative pour ce qui est des résultats entre les techniques chirurgicales ni dans les analyses de sous-groupes. Globalement, la flexion du poignet et la douleur ont diminué, et la force préhensile et autres paramètres autodéclarés par les patients se sont améliorés.Comparativement aux valeurs préopératoires globales, de modestes améliorations du score de douleur, de la force préhensile et des paramètres fonctionnels ont été obtenues au moyen de diverses interventions de reconstruction effectuées pour des blessures chroniques isolées du LISL. Aucune différence significative n’a pu être confirmée entre les techniques chirurgicales, probablement en raison de la faible qualité des données et de l’hétérogénéité des interventions. Cette étude fournit des valeurs de référence préopératoires précises pour de futures études et souligne l’impact clinique controversé de la classification de l’instabilité, ainsi que la nécessité de procéder à des essais multicentriques ou collaboratifs de meilleure qualité pour mieux comprendre et prendre en charge ce type fréquent de blessure.

Background: Direct oral anticoagulants (DOACs) are rapidly replacing warfarin for therapeutic anticoagulation; however, many DOACs are irreversible and may complicate bleeding in emergent situations such as hip fracture. In this setting, there is a lack of clear guidelines for the timing of surgery. The purpose of this study was to evaluate the current practices of Canadian orthopedic surgeons who manage patients with hip fracture receiving anticoagulation. Methods: In January–March 2018, we administered a purpose-specific cross-sectional survey to all currently practising orthopedic surgeons in Canada who had performed hip fracture surgery in 2017. The survey evaluated approaches to decision-making and timing of surgery in patients with hip fracture receiving anticoagulation. Results: A total of 280 surgeons representing a mix of academic and community practice, seniority and fellowship training responded. Nearly one-quarter of respondents (66 [23.4%]) were members of the Canadian Orthopaedic Trauma Society (COTS). Almost three-quarters (206 [73.6%]) felt that adequate clinical guidelines for patients with hip fracture receiving anticoagulation did not exist, and 177 (61.9%) indicated that anesthesiology or internal medicine had a greater influence on the timing of surgery than the attending surgeon. A total of 117/273 respondents (42.9%) indicated that patients taking warfarin should have immediate surgery (with or without reversal), compared to 63/270 (23.3%) for patients taking a DOAC (p < 0.001). Members of COTS were more likely than nonmembers to advocate for immediate surgery in all patients (p < 0.05). Conclusion: There is wide variability in Canada in the management of patients with hip fracture receiving anticoagulation. Improved multidisciplinary communication, prospectively evaluated treatment guidelines and focus on knowledge translation may add clarity to this issue. Level of evidence: IV.

Orthopaedic surgeons often speculate weather and season impact the nature and volume of surgical trauma. Little evidence exists to support this. We aimed to identify the relationship between weather conditions, time of year, surgical orthopaedic trauma volumes, after-hours surgery, and surgical wait times.Unscheduled surgical orthopaedic cases were retrospectively reviewed at major adult hospitals in Calgary, Alberta, Canada, over an eleven-year period (2008-2018). Weather variables were gathered and a predictive model for ice was generated. Multivariable Poisson regression was used to determine the effect of weather and time of year on orthopaedic trauma volumes and after-hours surgery. Linear regression was used to investigate surgical wait times.41,421 unscheduled orthopaedic trauma surgeries were analyzed against daily weather patterns. 49% of all surgery performed was for hip (26.4%) or ankle fractures (22.6%). Same day snow (p=0.002) and ice for two days prior (p=0.031; p=0.003) were significantly associated with increased overall trauma volumes. Same day snow (p0.001) and ice (p=0.002), as well as ice two days prior (p=0.001), predicted a significant increase in ankle fracture volumes. There was no correlation between weather patterns and hip fracture volumes. Independent of weather, time of year was highly predictive of large swings in orthopaedic trauma volumes and increased wait times. Generally, when patient volumes increased so did after-hours surgery.Winter and summer months as well as ice and daily snow contributed to the most significant increases in overall orthopaedic trauma volumes. On a snowy day in February with ice present for three consecutive days, trauma volumes increased as much as 71%. Despite this, resources dedicated to orthopaedic trauma are consistent throughout the year, which highlights the need to allocate resources for orthopaedic trauma surgery based on seasonal demands. We suggest our predictive model be used to guide the amount of operating room time reserved for orthopaedic trauma to better reflect expected volumes. This contrasts the current system which relies on after-hours surgeries and increased patient wait-times to compensate for increased orthopaedic trauma volumes. Since orthopaedic trauma can be predicted by weather patterns, interventions should aim to decrease weather-related orthopaedic trauma and reduce the burden prolonged wait times have on our system.

Objective To assess the use of ketotifen fumarate (KF) to reduce posttraumatic contractures after elbow fractures and/or dislocations. Design Randomized clinical trial. Setting Three hospitals in Calgary, Canada, including one Level 1 trauma center. Participants Adults (n = 151) sustaining operative or nonoperatively managed isolated distal humerus or proximal radius ± ulna fractures or elbow dislocations within 7 days of injury. Interventions KF 5 mg (n = 74) or lactose placebo (PL, n = 77) orally twice daily for 6 weeks. Main outcomes Primary outcome elbow flexion-extension arc range of motion (ROM) at 12 weeks postrandomization. Safety measures including serious adverse events and radiographic fracture line disappearance from 2 to 52 weeks postrandomization. Results The elbow ROM (mean, confidence interval) was not significantly different between KF (122 degrees, 118-127 degrees) and PL (124 degrees, 119-130 degrees) groups (P = 0.56). There was a significant difference in elbow ROM at 12 weeks postrandomization comparing operative (117 degrees, 112-122 degrees) versus nonoperative groups (128 degrees, 124-133 degrees) irrespective of intervention (P = 0.0011). There were 11 serious adverse events (KF = 6, PL = 5) that were those expected in an elbow fracture population potentially taking KF. There was no statistically significant difference in the rates of these events between the groups. The disappearance of fracture lines over the course of time was similar between groups. There was one nonunion in each group. Conclusions In a population of operative and nonoperatively managed elbow fractures and/or dislocations KF did not reduce posttraumatic contractures. The administration of KF in this population was not found to result in a significantly higher number of major adverse events when compared with placebo. Level of evidence Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background Injuries and resulting stiffness around joints, especially the elbow, have huge psychological effects by reducing quality of life through interference with normal daily activities such as feeding, dressing, grooming, and reaching for objects. Over the last several years and through numerous research results, the myofibroblast-mast cell-neuropeptide axis of fibrosis had been implicated in post-traumatic joint contractures. Pre-clinical models and a pilot randomized clinical trial (RCT) demonstrated the feasibility and safety of using Ketotifen Fumarate (KF), a mast cell stabilizer to prevent elbow joint contractures. This study aims to evaluate the efficacy of KF in reducing joint contracture severity in adult participants with operately treated elbow fractures and/or dislocations. Methods/design A Phase III randomized, controlled, double-blinded multicentre trial with 3 parallel groups (KF 2 mg or 5 mg or lactose placebo twice daily orally for 6 weeks). The study population consist of adults who are at least 18 years old and within 7 days of injury. The types of injuries are distal humerus (AO/OTA type 13) and/or proximal ulna and/or proximal radius fractures (AO/OTA type 2 U1 and/or 2R1) and/or elbow dislocations (open fractures with or without nerve injury may be included). A stratified randomization scheme by hospital site will be used to assign eligible participants to the groups in a 1:1:1 ratio. The primary outcome is change in elbow flexion-extension range of motion (ROM) arc from baseline to 12 weeks post-randomization. The secondary outcomes are changes in ROM from baseline to 6, 24 & 52 weeks, PROMs at 2, 6, 12, 24 & 52 weeks and impact of KF on safety including serious adverse events and fracture healing. Descriptive analysis for all outcomes will be reported and ANCOVA be used to evaluate the efficacy KF over lactose placebo with respect to the improvement in ROM. Discussion The results of this study will provide evidence for the use of KF in reducing post-traumatic joint contractures and improving quality of life after joint injuries. Trial registration This study was prospectively registered (July 10, 2018) with ClinicalTrials.gov reference: NCT03582176.

© 2020 Elsevier Ltd Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods: HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). Findings: Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4–9) in the accelerated-surgery group and 24 h (10–42) in the standard-care group (p

Objective We hypothesized that lengthening the scaphoid in a model of scapholunate ligament injury (SLI) will result in correction of radiographic markers of dorsal intercalated segment instability (DISI) deformity. Materials and Methods An SLI with DISI deformity was created by sectioning the SL ligament, the palmar radiocarpal ligaments, and scapho-trapezio-trapezoid ligaments of a cadaveric upper extremity (n = 5). The wrist was radiographed in both anteroposterior and lateral planes to confirm creation of SLI and DISI. The scaphoid was then osteotomized at its waist. A series of grafts (1–8 mm) were then placed at the osteotomy site. Radiographs were completed at each length. The main outcome measures were scapholunate interval (SL, mm), scapholunate angle (SLA, degrees), and radiolunate angle (RLA, degrees). These values, measured following the insertion of varying graft lengths, were compared with baseline measurements taken “post-injury” status. Results The ability to create an SLI with DISI was confirmed in the postinjury group with a statistically significant change in RLA, SLA, and SL compared with preinjury. With osteotomy and progressive insertion of spacers, the values improved into the accepted normal ranges for RLA (6 mm) and SLA (4 mm) with scaphoid lengthening. Conclusions In this cadaveric model of SL injury, radiographic markers of DISI were returned to within normal ranges with scaphoid osteotomy and lengthening. Clinical Relevance The results of this study add insight into wrist kinematics in our injury model and may represent a potential future direction for surgical treatment of SLI.

Objectives: The aim of this study is to report the impact of public health measures (PHM), including their relaxation, on surgical orthopaedic trauma volumes. We hypothesize an initial reduction in orthopaedic trauma volumes during lockdown followed by a surge as Stages 1 and 2 of reopening progressed in Summer 2020. Methods: All unscheduled surgical orthopaedic trauma cases from March through August were retrospectively reviewed in Calgary, Alberta, Canada, from 2008 to 2020. Trauma volumes from 2008 to 2019 were used to model expected 2020 volumes, and multivariable Poisson regression was used to determine the effect of PHM on orthopaedic trauma volumes. Results: A total of 22,331 trauma orthopaedic surgeries were included. During lockdown, there was a significant decrease in trauma volume compared with expected (-14.2%, -25.7 to -10.5%, P 

Category: Ankle; Hindfoot; Midfoot/Forefoot; Trauma. Introduction/Purpose: To aid in healing and avoid costly revision surgery, bone grafts, growth factors, and bone stimulation devices are used as adjuncts to foot/ankle arthrodesis. This study evaluated the union rates of LIPUS as an adjunct to foot/ankle arthrodesis and the corresponding factors associated with improved healing. Methods: Foot/ankle arthrodesis patients were identified retrospectively from a prospective post-market arthrodesis/fracture registry for EXOGEN (Bioventus LLC, Durham, NC). Inclusion criteria were males or non-pregnant females 18 years of age or older at time of enrollment, known date of fracture, known start and end dates of LIPUS treatment, and known treatment success outcome. Treatment success was defined by both clinical (solid and pain-free on manual stress) and radiological (at least 3 of 4 cortices bridged on x-rays) criteria. Association between union rates and surgical treatments, comorbidities, and medications was tested with Chi-square tests. Results: A total of 235 primary and 16 revision foot/ankle arthrodesis patients used EXOGEN. 41.4% used EXOGEN within 90 days of the fracture/arthrodesis. Overall union rate was 86.9% (primary: 86.4%; revision: 93.8%). Having the comorbidity of diabetes, obesity, or current smoker was not associated with a higher non-union rate (p=0.779). Other comorbidities were also not associated with increased non-union rates (e.g., Charcot disease p=0.614, NSAID p=0.862, steroids p=0.647). EXOGEN use within 90 days of the fracture/procedure date was associated with improved union rates for the overall (p=0.004, odds ratio (OR) 3.7 (95% CI: 1.5-9.3)) and primary (p=0.007, OR 3.4 (95% CI: 1.3-8.6)) groups. For the overall group, union rates were 94.2% (EXOGEN use 365 days). Conclusion: Union rates for foot/ankle arthrodesis with adjunctive LIPUS were comparable to other therapies with and without other adjuncts (Table 1). Known risk factors for non-union, such as smoking and Charcot disease, were not found to be associated with healing for the LIPUS patients. This suggests the possibility that LIPUS was able to mitigate potential patient risk factors and may offer a low risk post-operative adjunct in difficult healing scenarios. [Table: see text]

Background: Effective teamwork is highly reliant on both technical and non-technical skills (such as communication, decision making and situational awareness). In healthcare, the role of non-technical skills fails to take priority and can hinder a team’s performance. Methods: Our objective was to determine the effectiveness and efficacy of delivering a full-day professional development symposium focused on communication strategies and culture building to the operating room staff at a hospital with over 250 acute beds. A prospective, observational cohort study including all members of the operating room was designed. Improvement was measured through an anonymous, voluntary, web-based survey and surrogate metrics of improved communication and positive work culture (staff turnover, sick days and spending). Results: 82 participants completed at least one survey. At three months post-symposium, more than 60% of participants noticed that their colleagues made active efforts to communicate positively and effectively in their interactions (p = 0.009). At this same interval, staff reported a reduction in common challenges routinely encountered in the operating room. Sick days fell from 622 in the year preceding the symposium to 218 in the year following the symposium. Staff turnover fell from nine to two in that same interval while OR spending was reduced by 4.2%. Interpretation: Results from our cohort suggest that a focused, professional development symposium with emphasis on communication strategies may improve operating room culture and yield both cost savings and improved patient care. More quality-controlled research with a rigorous study design is needed to assess the impact of communication training in an OR setting.

The scapholunate ligament is both a key ligament in the stability of the carpus and one of the most frequently injured. Thorough understanding of the anatomy, biomechanics, and pathophysiology of the wrist is important in treating injuries to the scapholunate ligament. The presentation of scapholunate instability often includes a vague injury history and pain with grip, wrist extension, and sport or labor. Identified injuries are classified based on dynamic and static radiographic findings, chronicity, and the presence or absence of arthrosis. Surgical options for the treatment of low- and high-grade injuries include both open and arthroscopic procedures and can be broadly classified into four categories: limited arthroscopic procedures, primary ligament repair, reconstructive procedures, and salvage procedures. No strong evidence currently supports any one treatment. Decision making is largely based on expert opinion and surgeon experience. Prognosis is often guarded, and patient expectations should be tempered.

This study identifies and corrects instrumental drift for satellite altimeter missions, which affects estimates of the rates of sea-level rise. Corrected data show an acceleration in the rate of rise, counter to previous estimates and in line with projections.

Confidence in projections of global-mean sea level rise (GMSLR) depends on an ability to account for GMSLR during the twentieth century. There are contributions from ocean thermal expansion, mass loss from glaciers and ice sheets, groundwater extraction, and reservoir impoundment. Progress has been made toward solving the “enigma” of twentieth-century GMSLR, which is that the observed GMSLR has previously been found to exceed the sum of estimated contributions, especially for the earlier decades. The authors propose the following: thermal expansion simulated by climate models may previously have been underestimated because of their not including volcanic forcing in their control state; the rate of glacier mass loss was larger than previously estimated and was not smaller in the first half than in the second half of the century; the Greenland ice sheet could have made a positive contribution throughout the century; and groundwater depletion and reservoir impoundment, which are of opposite sign, may have been approximately equal in magnitude. It is possible to reconstruct the time series of GMSLR from the quantified contributions, apart from a constant residual term, which is small enough to be explained as a long-term contribution from the Antarctic ice sheet. The reconstructions account for the observation that the rate of GMSLR was not much larger during the last 50 years than during the twentieth century as a whole, despite the increasing anthropogenic forcing. Semiempirical methods for projecting GMSLR depend on the existence of a relationship between global climate change and the rate of GMSLR, but the implication of the authors' closure of the budget is that such a relationship is weak or absent during the twentieth century.

In the interest of improving the sea level climate data record, we compare the 19-year global mean sea level (GMSL) time series derived from TOPEX-Poseidon, Jason-1, and Jason-2 and produced by different research institutions. The GMSL time series are each produced using varying techniques and different applied corrections, and subsequently, the time series exhibit unique characteristics and sensitivity to seasonal and interannual signals. We find that the different applied corrections affect the time series variability much less than the technique for computing the GMSL from along-track versus gridded sea surface height anomalies and the choice of a minimum depth criteria.

Several methods have been reported for fixation of displaced phalangeal neck fractures in children. The purpose of this study is to present a technique for the closed reduction and percutaneous fixation of displaced phalangeal neck fractures and the clinical results of 4 patients treated by this method.Four consecutive patients with displaced phalangeal neck fractures were treated with closed reduction and single intramedullary Kirschner wire placed percutaneously with a novel technique.The average age at injury was 5 years 9 months (range, 23 mo to 10 y). Three patients were male and 1 was female. Two patients had fractures of the proximal phalangeal neck, whereas the other 2 had fractures of the middle phalangeal neck. After an average follow-up of 18 weeks, all patients had nearly full pain-free flexion and extension of the affected digit.The described technique is a simple, reproducible and effective treatment for displaced phalangeal neck fractures in children.Level IV. Therapeutic study, case series.

Purpose Unstable dorsal fracture–dislocations of the proximal interphalangeal (PIP) joint are complex injuries that are difficult to treat and usually require operative fixation. There are a number of surgical techniques for treating these injuries but none has emerged as superior. The purposes of this study were to describe a simple percutaneous technique to treat unstable dorsal fracture–dislocations of the PIP joint and to report short-term postoperative results. Methods We treated 6 patients with unstable dorsal fracture–dislocations of the PIP joint with the technique of closed reduction, percutaneous fracture reduction, and pinning via a volar approach and also with dorsal block pinning. We collected information on postoperative stability, range of motion at the PIP and distal interphalangeal joints, and radiographic outcomes. We also administered the Disabilities of the Arm, Shoulder, and Hand and visual analog pain scale questionnaires. Results At a mean follow-up of 18 months (range, 6–57 mo), there were no subluxation or dislocation events. The mean range of motion was from 4° of extension to 93° of flexion at the PIP joint and from 1° of extension to 73° of flexion at the distal interphalangeal joint. Radiographic analysis revealed a concentric reduction and union in all cases. The mean Disabilities of the Arm, Shoulder, and Hand score was 8 and the mean visual analog pain score was 1.4 out of 10. There were no minor or major complications. Conclusions This percutaneous technique reliably restored stability to the PIP joint, allowed for concentric reduction of the joint, and produced excellent radiographic and clinical outcomes. The postoperative management course with this technique is critical to the outcome. Type of study/level of evidence Therapeutic IV.

Updated absolute bias estimates are presented from the Bass Strait calibration site (Australia) for the TOPEX/Poseidon (T/P), Jason-1 and the Ocean Surface Topography Mission (OSTM/Jason-2) altimeter missions. Results from the TOPEX side A and side B data show biases insignificantly different from zero when assessed against our error budget (−15 ± 20 mm, and −6 ± 18 mm, respectively). Jason-1 shows a considerably higher absolute bias of +93 ± 15 mm, indicating that the observed sea surface is higher (or the range shorter), than truth. For OSTM/Jason-2, the absolute bias is further increased to +172 ± 18 mm (determined from T/GDR data, cycles 001–079). Enhancements made to the Jason-1 and OSTM/Jason-2 microwave radiometer derived products for correcting path delays induced by the wet troposphere are shown to benefit the bias estimate at the Bass Strait site through the reduction of land contamination. We note small shifts to bias estimates when using the enhanced products, changing the biases by +11 and +3...

There is intense scientific and public interest in the Intergovernmental Panel on Climate Change (IPCC) projections of sea level for the twenty-first century and beyond. The Fourth Assessment Report (AR4) projections, obtained by applying standard methods to the results of the World Climate Research Programme Coupled Model Experiment, includes estimates of ocean thermal expansion, the melting of glaciers and ice caps (G&ICs), increased melting of the Greenland Ice Sheet, and increased precipitation over Greenland and Antarctica, partially offsetting other contributions. The AR4 recognized the potential for a rapid dynamic ice sheet response but robust methods for quantifying it were not available. Illustrative scenarios suggested additional sea level rise on the order of 10 to 20 cm or more, giving a wide range in the global averaged projections of about 20 to 80 cm by 2100. Currently, sea level is rising at a rate near the upper end of these projections. Since publication of the AR4 in 2007, biases in historical ocean temperature observations have been identified and significantly reduced, resulting in improved estimates of ocean thermal expansion. Models that include all climate forcings are in good agreement with these improved observations and indicate the importance of stratospheric aerosol loadings from volcanic eruptions. Estimates of the volumes of G&ICs and their contributions to sea level rise have improved. Results from recent (but possibly incomplete) efforts to develop improved ice sheet models should be available for the 2013 IPCC projections. Improved understanding of sea level rise is paving the way for using observations to constrain projections. Understanding of the regional variations in sea level change as a result of changes in ocean properties, wind-stress patterns, and heat and freshwater inputs into the ocean is improving. Recently, estimates of sea level changes resulting from changes in Earth's gravitational field and the solid Earth response to changes in surface loading have been included in regional projections. While potentially valuable, semi-empirical models have important limitations, and their projections should be treated with caution

SUMMARY Through the combination of rare historical sea level observations collected during Sir Douglas Mawson’s 1911–1914 Australasian Antarctic Expedition (AAE), together with modern sea level data, space geodetic estimates of crustal displacement and modelling of coseismic and post-seismic earthquake deformation, we present a contemporary analysis to constrain sea level and land level change over the twentieth century at Macquarie Island (54 ◦ 30 � S, 158 ◦ 57 � E). We combine 9 months of 1912–1913 sea level data with intermediate observations in 1969–1971, 1982 and 1998–2007 to estimate sea level rise relative to the land at +4.8 ± 0.6 mm yr −1 . Combined with estimates of global mean sea level rise, this value supports the geologically surprising notion of land subsidence, conflicting with longer term geological evidence that suggests uplift at ∼0.8 mm yr −1 over the last 400–300 Kyr. We investigate the current tectonic evolution of the Island through analysis of Global Positioning System (GPS) solutions that utilize data over the period 2000–2009. Importantly, this provides an opportunity to refine the source parameters of the M w ∼8.0 great earthquake of 2004 December 23 using estimates of coseismic displacements at regional GPS sites. We use the estimated earthquake source and GPS observations of four years of post-seismic deformation at Macquarie Island to infer the rheology of the oceanic upper mantle. We find that an asthenosphere bounded by stronger material above and below is required to produce the observed post-seismic deformation, particularly in the vertical component. Assuming a Maxwell rheology, the best fit is given by an asthenospheric viscosity of 3×10 19 Pa s. The inferred rheology determined from the 2004 earthquake is used to model long period post-seismic deformation from M w ∼8.0 earthquakes of 1989 and 1924. The 1924 earthquake is the closest of the three great earthquakes to Macquarie Island, and our modelling suggests that the majority of the vertical deformation at the tide gauge over the subsequent 80 years is related to ongoing viscoelastic relaxation from this thrust earthquake that ruptured south from an epicentre south of Macquarie Island. Assimilated time-series of land level change from the earthquake modelling (suggesting ongoing subsidence) constrained by the GPS estimate of vertical velocity of −2.46 ± 0.64 mm yr −1 combine with the relative sea level time-series to yield an estimate of absolute sea level change of +2.0 ± 0.8 mm yr −1 over the twentieth century. We conclude this is consistent with the upper bound of the global average rate of absolute sea level rise over the same period. This represents one of few estimates of observed sea level change in the Southern Ocean, re-emphasizing the importance of historical data and continued geodetic and oceanographic observation in remote areas.

Adaptive practices are taking place in a range of sectors and regions in Australia in response to existing climate impacts, and in anticipation of future unavoidable impacts. For a rich economy such as Australia’s, the majority of human systems have considerable adaptive capacity. However, the impacts on human systems at the intra-nation level are not homogenous due to their differing levels of exposure, sensitivity and capacity to adapt to climate change. Despite past resilience to changing climates, many Indigenous communities located in remote areas are currently identified as highly vulnerable to climate impacts due to their high level of exposure and sensitivity, but low capacity to adapt. In particular, communities located on low-lying islands have particular vulnerability to sea level rise and increasingly intense storm surges caused by more extreme weather. Several Torres Strait Island community leaders have been increasingly concerned about these issues, and the ongoing risks to these communities’ health and well-being posed by direct and indirect climate impacts. A government agency is beginning to develop short-term and long-term adaptation plans for the region. This work, however, is being developed without adequate scientific assessment of likely ‘climate changed futures.’ This is because the role that anthropogenic climate change has played, or will play, on extreme weather events for this region is not currently clear. This paper draws together regional climate data to enable a more accurate assessment of the islands’ exposure to climate impacts. Understanding the level of exposure and uncertainty around specific impacts is vital to gauge the nature of these islands’ vulnerability, in so doing, to inform decisions about how best to develop anticipatory adaptation strategies over various time horizons, and to address islanders’ concerns about the likely resilience and viability of their communities in the longer term.

A modification in the rate of change of sea level (i.e. an ‘acceleration’ or ‘nonlinear trend’) is an important climate-related signal, which requires confirmation and explanation. In this study, the evidence for accelerations in regional and global average sea level on timescales of several decades and longer is reviewed by inter-comparison of the recent findings of different researchers and by inspection of original tide gauge records. Most sea-level data originate from Europe and North America, and both the sets display evidence for a positive acceleration, or ‘inflexion’, around 1920–1930 and a negative one around 1960. These inflexions are the main contributors to reported accelerations since the late 19th century, and to decelerations during the mid- to late 20th century. However, these characteristic features are not always found in records from other parts of the world. Although some aspects of the sea-level time series are consistent with changes in rates of globally averaged temperature changes, volcanic eruptions and natural climate variability, modelling undertaken so far has been unable to describe these features adequately. This emphasizes the need for a major enhancement of the sea-level data set, especially for those parts of the world without long tide gauge records, in order to obtain greater insight into the spatial dependence of accelerations. A number of complementary methods must be employed, of which salt marsh techniques offer the possibility of obtaining time series similar to those that would have been obtained from coastal tide gauges. Copyright © 2008 Royal Meteorological Society

Historical and projected sea-levels for islands in the tropical Pacific and Indian oceans are a subject of considerable interest and some controversy. The large variability (e.g. El Nino) signals and the shortness of many of the individual tide-gauge records contribute to uncertainty of historical rates of sea-level rise. Here, we determine rates of sea-level rise from tide gauges in the region. We also examine sea-level data from the TOPEX/Poseidon satellite altimeter and from a reconstruction of sea level in order to put the sparse (in space and time) tide-gauge data into context. For 1993 to 2001, all the data show large rates of sea-level rise over the western Pacific and eastern Indian Ocean (approaching 30 mm yr −1 ) and sea-level falls in the eastern Pacific and western Indian Ocean (approaching −10 mm yr −1 ). Over the region 40°S to 40°N, 30°E to 120°W, the average rise is about 4 mm yr −1 . For 1950 to 2001, the average sea-level rise (relative to land) from the six longest tide-gauge records is 1.4 mm yr −1 . After correcting for glacial isostatic adjustment and atmospheric pressure effects, this rate is 2.0 mm yr −1 , close to estimates of the global average and regional average rate of rise. The long tide-gauge records in the equatorial Pacific indicate that the variance of monthly averaged sea-level after 1970 is about twice that before 1970. We find no evidence for the fall in sea level at the Maldives as postulated by Morner et al. (2004). Our best estimate of relative sea-level rise at Funafuti, Tuvalu is 2±1 mm yr −1 over the period 1950 to 2001. The analysis clearly indicates that sea-level in this region is rising. We expect that the continued and increasing rate of sea-level rise and any resulting increase in the frequency or intensity of extreme sea-level events will cause serious problems for the inhabitants of some of these islands during the 21st century.

Peripheral quantitative computed tomography (pQCT) can assess bone geometric properties and separate cortical from trabecular bone. Despite pQCT's potential benefits for research, most reliability and accuracy studies have used a constant acquisition and analysis protocol. There are, however, numerous steps in the pQCT scan acquisition and analysis that are operator dependent. Whether or not these influence the quality of the pQCT scans and, potentially, the precision and validity of the data collected has been little explored. We investigated how pQCT outputs changed when operator-dependent parameters were varied, particularly when the bone of interest was of low mineral density. We found that bone parameters and scan failure rate varied significantly depending on the acquisition resolution; only one scan slice at the 10 and 30% radius is required to maintain adequate precision, and reference lines for sites should use a reproducible landmark. These results provide a foundation for recommending scan acquisition and analysis options for patients with low bone mass.

TOPEX/Poseidon satellite altimeter data are used to estimate global empirical orthogonal functions that are then combined with historical tide gauge data to estimate monthly distributions of large-scale sea level variability and change over the period 1950-2000. The reconstruction is an attempt to narrow the current broad range of sea level rise estimates, to identify any pattern of regional sea level rise, and to determine any variation in the rate of sea level rise over the 51-yr period. The computed rate of global-averaged sea level rise from the reconstructed monthly time series is 1.8 +/- 0.3 mm yr(-1). With the decadal variability in the computed global mean sea level, it is not possible to detect a significant increase in the rate of sea level rise over the period 1950-2000. A regional pattern of sea level rise is identified. The maximum sea level rise is in the eastern off-equatorial Pacific and there is a minimum along the equator, in the western Pacific, and in the eastern Indian Ocean. A greater rate of sea level rise on the eastern North American coast compared with the United Kingdom and the Scandinavian peninsula is also found. The major sources of uncertainty are the inadequate historical distribution of tide gauges, particularly in the Southern Hemisphere, inadequate information on tide gauge signals from processes such as postglacial rebound and tectonic activity, and the short satellite altimeter record available to estimate global sea level covariance functions. The results demonstrate that tide gauge records will continue to complement satellite altimeter records for observing and understanding sea level change.

Updated absolute calibration results from Bass Strait, Australia, are presented for the TOPEX/Poseidon (T/P) and Jason-1 altimeter missions. Data from an oceanographic mooring array and coastal tide gauge have been used in addition to the previously described episodic GPS buoy deployments. The results represent a significant improvement in absolute bias estimates for the Bass Strait site. The extended methodology has allowed comparison between the altimeter and in situ data on a cycle-by-cycle basis over the duration of the dedicated calibration phase (formation flight period) of the Jason-1 mission. In addition, it has allowed absolute bias results to be extended to include all cycles since the T/P launch, and all Jason-1 data up to cycle 60. Updated estimates and formal 1-sigma uncertainties of the absolute bias computed throughout the formation flight period are 0 ± 14 mm for T/P and +152 + 13 mm for Jason-1 (for the GDR POE orbits). When JPL GPS orbits are used for cycles 1 to 60, the Jason-1 bias est...

An absolute calibration of the TOPEX/Poseidon (T/P) and Jason-1 altimeters has been undertaken during the dedicated calibration phase of the Jason-1 mission, in Bass Strait, Australia. The present study incorporates several improvements to the earlier calibration methodology used for Bass Strait, namely the use of GPS buoys and the determination of absolute bias in a purely geometrical sense, without the necessity of estimating a marine geoid. This article focuses on technical issues surrounding the GPS buoy methodology for use in altimeter calibration studies. We present absolute bias estimates computed solely from the GPS buoy deployments and derive formal uncertainty estimates for bias calculation from a single overflight at the 40-45 mm level. Estimates of the absolute bias derived from the GPS buoys is -10 ± 19 mm for T/P and + 147 ± 21 mm for Jason-1 (MOE orbit) and + 131 ± 21 mm for Jason-1 (GPS orbit). Considering the estimated error budget, our bias values are equivalent to other determinations from the dedicated NASA and CNES calibration sites.

Basal joint arthritis leads to thumb metacarpophalangeal (MCP) hyperextension that may prevent physiologic pinch. Various techniques have been used to address this hyperextension, but most are technically challenging, time-consuming, and not supported by long-term follow-up results. Furthermore, few groups have reported subjective, patient-based outcomes after such procedures. In a retrospective study, we evaluated a cohort of 14 patients who underwent a novel technique of thumb MCP capsulodesis in conjunction with basal joint arthroplasty. A mean of 4.74 years after surgery, subjective outcome measures (Disabilities of the Arm, Shoulder, and Hand questionnaire; visual analog scale for pain; patient satisfaction) and objective outcome measures (range of motion, grip and pinch strengths) all reflected excellent function. The described technique for MCP capsulodesis is an attractive adjunct to basal joint arthroplasty, but further prospective studies are needed to establish specific operative indications.

Background:Many patients with suspected scaphoid fractures but negative radiographs are immobilized for ≥ 2 weeks and are eventually found to have no fracture. Bone scans are reportedly 99% sensitive for these injuries if done ≥ 72 hours postinjury.Objective:The purpose of this study was to determine if early bone scans would allow for shorter cast immobilization periods in patients with suspected scaphoid fractures.Methods:Twenty-seven patients with clinically suspected scaphoid fractures and negative radiographs were randomized to early diagnosis (bone scan within 3–5 days; n 5 12) or traditional diagnosis (radiographs 10–14 days postinjury; n 5 15). The primary outcome was number of days immobilized in a cast.Results:The mean number of days immobilized was 26 in the traditional group and 29 in the bone scan group. Overall, 6 patients had scaphoid fractures (2 in the traditional diagnosis group and 4 in the bone scan group; p > 0.05), and 8 had other types of fractures. These other types of fractures included four distal radius fractures, two triquetral fractures, one trapezoid fracture, and one hamate fracture. There was no significant difference in the number of other types of fractures between groups. The Kaplan-Meier survival analysis using the log-rank test revealed that there was no statistically significant difference between days immobilized between the radiograph and bone scan groups (p 5 0.38).Conclusions:The current study suggests that the use of bone scans to help diagnose occult scaphoid fractures does not reduce the number of days immobilized and that the differential diagnosis of occult scaphoid fractures should remain broad because other injuries are common.

This 16-year-old boy with Proteus syndrome suffered acute spinal cord compression secondary to hemorrhage into an extradural paraspinal angiolipomatous hamartoma. A magnetic resonance (MR) imaging study performed 12 years earlier had revealed the presence of this tumor at the apex of a mild thoracic scoliosis, which had been stable during the intervening decade. Spinal cord neurological deficit in Proteus syndrome is rare. It can arise either from vertebral abnormalities and kyphoscoliotic deformities or from tumor encroachment. The authors describe the temporal evolution of scoliosis and acute spinal cord compression caused by a paraspinal angiolipomatous hamartoma over a period of 12 years. A review of the literature suggests that regular follow up, including serial MR imaging, is indicated in children with Proteus syndrome and scoliosis. Earlier resection of extradural tumor mass encroaching on the cord is warranted in the treatment of these children.

The ocean has the largest heat capacity in the climate system and as a result the ocean plays a critical role in the climate. Changes in ocean heat content dominate the Earth’s energy storage; and the ocean’s thermal expansion has been a major contributor to sea-level rise in the twentieth century and likely to be the largest contributor in the twenty-first century. The agreement between changes in ocean heat storage over recent decades and changes in the Earth’s radiative balance, within uncertainties, provides strong support for current understanding of anthropogenic climate change. As a result of improvements in observations and modeling of sea level and components contributing to sea-level change, there is now an improved explanation for twentieth century sea-level rise. Models project a continuing sea-level rise during the twenty-first century and beyond. However, a number of uncertainties remain in our understanding of the global mean and regional distribution of sea-level rise resulting from changes in ocean circulation and changes in the Earth’s gravitational field. Ocean-ice-sheet interactions are important for quantitatively estimating future ice-sheet contributions to sea-level rise.

Ankle fractures are among the most common injuries treated by orthopedic surgeons.1,2 It has been established that anatomic reduction, including length and alignment of the fibula, in displaced ankle fractures is essential for best possible outcomes.3–12 One-third tubular plates, dynamic compression plates (LCDCP) and locking plates have been used. Absolute stability with interfragmentary screw fixation is the gold standard when technically possible.3,4,13 When fractures are comminuted or associated with high-energy tibia fractures, many authors advocate the use of LCDCP to gain added construct stiffness.14–16 To our knowledge, there is no evidence in the literature to direct plate selection when using bridge plate fixation in comminuted fibular fractures. When fibular fractures occur in osteoporotic bone, augmentation with intramedullary K-wires or screws through the tibia have been advocated.17,18 More recently, locking plates have been used in many areas of the body, often for comminuted fractures, short metaphyseal segments and osteoporotic fractures.19–23 The LCDCP has been shown to add stiffness to a fracture construct compared with one-third tubular plating.16,24 The disadvantage is a bulkier plate in a directly subcutaneous location that causes more frequent hardware irritation and results in subsequent removal.11,25 One-third tubular locked bridge plating offers a low profile construct while potentially providing greater stiffness than standard one-third tubular plating. The present study was designed to compare 2 types of bridge plate fixation of a comminuted fibular fracture. Paired laboratory-recreated comminuted fibular fractures (Weber C, Lauge-Hansen pronation–external rotation, AO/ASIF 44C2.1) were plated using either locked or standard one-third tubular bridge plating techniques. They were loaded to catastrophic failure to assess biomechanical properties, with the primary outcome being construct stiffness.

Hypothesis Many investigators agree that 2 mm of articular displacement is a reasonable indication for open reduction and internal fixation of Mason type II fractures of the radial head. However, there is no evidence to support that this degree of articular displacement is predictive of poor outcomes in conservatively treated fractures. We hypothesized there would be no difference between conservatively treated radial head fractures with greater 2 mm of displacement and those with less than 2 mm of displacement in terms of patient-reported or clinical outcomes. Materials and methods We reviewed databases of all radial head fractures in our region. The primary outcomes were the Patient-Rated Elbow Evaluation and Disabilities of the Arm, Shoulder and Hand questionnaires. Secondary outcomes included radiologic radiocapitellar arthritis and range of motion (ROM) at follow-up. Postinjury treatment protocols, as well as patient factors, were examined for their effects on outcome. Results The results showed no significant difference in any outcome for conservatively treated radial head fractures with 2 mm ( P = .8) or even 3 mm ( P = .6) of articular displacement over a mean follow-up of 4.4 years. Early ROM and physiotherapy showed no significant differences in any outcome measure. Dominant hand injury showed no significant difference in patient-reported outcomes; however, ROM was significantly decreased on examination. Conclusions This retrospective review suggests that fracture displacement of 2 to 3 mm is not necessarily an indication for surgical fixation in isolated fractures of the radial head. In addition, it appears that postinjury ROM/physiotherapy does not play a large role in improving patient outcome.

We review the sea-level and energy budgets together from 1961, using recent and updated estimates of all terms. From 1972 to 2008, the observed sea-level rise (1.8 ± 0.2 mm yr−1 from tide gauges alone and 2.1 ± 0.2 mm yr−1 from a combination of tide gauges and altimeter observations) agrees well with the sum of contributions (1.8 ± 0.4 mm yr−1) in magnitude and with both having similar increases in the rate of rise during the period. The largest contributions come from ocean thermal expansion (0.8 mm yr−1) and the melting of glaciers and ice caps (0.7 mm yr−1), with Greenland and Antarctica contributing about 0.4 mm yr−1. The cryospheric contributions increase through the period (particularly in the 1990s) but the thermosteric contribution increases less rapidly. We include an improved estimate of aquifer depletion (0.3 mm yr−1), partially offsetting the retention of water in dams and giving a total terrestrial storage contribution of −0.1 mm yr−1. Ocean warming (90% of the total of the Earth's energy increase) continues through to the end of the record, in agreement with continued greenhouse gas forcing. The aerosol forcing, inferred as a residual in the atmospheric energy balance, is estimated as −0.8 ± 0.4 W m−2 for the 1980s and early 1990s. It increases in the late 1990s, as is required for consistency with little surface warming over the last decade. This increase is likely at least partially related to substantial increases in aerosol emissions from developing nations and moderate volcanic activity.

On a recent mission directed at definitive care for victims of the Haitian earthquake, the orthopaedic team developed a technique for freehand distal locking of femoral and tibial nails without intraoperative fluoroscopy or proximally mounted targeting jigs.After performing open antegrade or retrograde nailing by standard techniques, the freehand lock must be obtained before doing standard outrigger locking. This allows the surgeon to control the nail and deliver the locking hole in the nail to a unicortical drill hole in the femur. Before nail insertion, the distance of the desired locking hole is measured from the outrigger in a standard way such that it can be reproduced after the nail is inserted. Through a unicortical drill hole, the nail is palpated with the tip of a Kirschner wire and systematic maneuvers allow the Kirschner wire to palpate and fall into the locking hole. The Kirschner wire is tapped across the second cortex before drilling. The screw is inserted, and the ball-tipped insertion guidewire is placed back into the nail to palpate the crossing screw confirming position.We treated 16 patients with 18 long bone fractures using the described technique. We assessed patients clinically and radiographically immediately postoperatively.A total of 19 blind freehand interlocks were attempted, and 17 were successful as assessed by direct intraoperative observations and by postoperative radiographs.We describe a simple technique for performing static locked intramedullary nailing of the femur and tibia without fluoroscopy. This technique was successful in most cases and is intended for use with any nailing system only when fluoroscopy or specialized systems for nailing without fluoroscopy are not available.