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Introduction: Incarceration of intramedullary nails can pose a significant challenge. There are many reported techniques of nail removal, but when these fail, it can be difficult to determine how to proceed. Here, it is shown that a proximal femoral episiotomy can be used with great effect., Case Report: 64-year-old male developed hip arthritis. The patient had a solid antegrade femoral nail placed 22 years ago that required removal for a hip arthroplasty. A proximal femoral episiotomy-assisted approach was used with good results and patient outcome., Conclusion: There are several well described techniques to assist with incarcerated nail removal that all trauma surgeons should be familiar with. Proximal femoral episiotomy is a useful technique, every surgeon should have in their arsenal., Competing Interests: Conflict of Interest: Nil, (Copyright: © Indian Orthopaedic Research Group.)

Two analytic traditions characterize fMRI language research. One relies on averaging activations across individuals. This approach has limitations: because of inter-individual variability in the locations of language areas, any given voxel/vertex in a common brain space is part of the language network in some individuals but in others, may belong to a distinct network. An alternative approach relies on identifying language areas in each individual using a functional 'localizer'. Because of its greater sensitivity, functional resolution, and interpretability, functional localization is gaining popularity, but it is not always feasible, and cannot be applied retroactively to past studies. To bridge these disjoint approaches, we created a probabilistic functional atlas using fMRI data for an extensively validated language localizer in 806 individuals. This atlas enables estimating the probability that any given location in a common space belongs to the language network, and thus can help interpret group-level activation peaks and lesion locations, or select voxels/electrodes for analysis. More meaningful comparisons of findings across studies should increase robustness and replicability in language research., (© 2022. The Author(s).)

Developing a low-cost depyrogenation process is vital in extending medical applicability of polymers that can be used in medicine. We present an overview of the plasma-based depyrogenation literature and address the need to develop a non-thermal plasma-based depyrogenation process for delicate materials such as chitosan. We present a low-cost plasma apparatus to treat chitosan powder in hermetically sealed bags. We decouple the experiments into two; depyrogenation experiments for dried standard endotoxin on glass slides, and chitosan modifications analysis through FTIR spectroscopy. We demonstrate depyrogenation efficacy with up to a 4-log reduction in endotoxin levels and discuss minor changes observed in plasma-treated chitosan.

Objectives: Fellowship-trained orthopaedic traumatologists are presumably taught skill sets leading to "best practice" outcomes and more efficient use of hospital resources. This should result in more favorable economic opportunities when compared with general orthopaedic surgeons (GOSs) providing similar clinical services. The purpose of our study was to compare the operating room utilization and financial data of traumatologists versus GOSs at a level II trauma center., Design: Retrospective review., Setting: Level II community-based trauma hospital., Patients/participants: Patients who presented to the emergency room at our institution with fractures and orthopaedic conditions requiring surgical intervention from January 1, 2010, to December 31, 2011., Intervention: Operative fracture fixation by members of our orthopaedic trauma panel, including fellowship and nontrauma fellowship-trained orthopaedic surgeons., Main Outcome Measurements: Our institutional database was queried to determine operative times, surgical supply and implant costs, and surgery labor expenses. Patients were stratified according to those treated by our trauma panel's 3 traumatologists and those treated by the 15 GOSs on our trauma panel. These 2 groups were then compared using standard statistical methods., Results: A total of 6449 orthopedic cases were identified and 2076 of these involved fracture care. One thousand one hundred ninety-nine patients were treated by traumatologists and 877 by GOSs. There was no statistical difference detected in American Society of Anesthesiologists score between trauma and nontrauma groups. Overall, the traumatologist group demonstrated significantly decreased procedure times when compared with the GOS group (55.6 vs. 75.8 minutes, P , 0.0001). In 16 of 18 most common procedure types, traumatologists were more efficient. This led to significantly decreased surgical labor costs ($381.4 vs. $484.8; P < 0.0001) and surgical supply and implant costs ($2567 vs. $3003; P < 0.0001)., Conclusions: This study demonstrates that in our communitybased trauma system, fracture care provided by traumatologists results in improved utilization of hospital-based resources when compared with equivalent services provided by GOSs. Significantly decreased operative times, surgical labor expenses, and supply and implant costs by the fellowship-trained group represent enhanced control of the design, plan, execution, and monitoring of orthopaedic trauma care. Traumatologists can provide leadership recommendations for operating room efficiency in community-based orthopaedic trauma care models., Level of Evidence: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives: The American Academy of Orthopedic Surgeons and the Orthopedic Trauma Association have released guidelines for the provision of orthopedic trauma services such as adequate stipends, designated operating rooms, ancillary staff, and guaranteed reimbursement for indigent care. One recommendation included a provision for hospital-based physician assistants (PAs). Given current reimbursement arrangements, PA collections for billable services may not meet their salary and benefit expenses. However, their actions may indirectly affect emergency room, operating room, and hospital reimbursement and patient care itself. The purpose of our study is to define the true impact of hospitalbased PAs on orthopaedic trauma care at a level II community hospital., Design: Retrospective case series., Setting: Level II trauma center., Patients/participants: One thousand one hundred four trauma patients with orthopaedic injuries., Intervention: PA involvement., Main Outcome Measurements: Emergency room data such as triage time, time until seen by the orthopedic service, and total emergency room time was recorded. Operating room data such as time to surgery, set-up time, total operating time, and out of room time was entered as well. Charts were reviewed to determine if patients were given postoperative antibiotics and Deep Venous Thrombosis (DVT) prophylaxis. Intraoperative and postoperative complications were noted, and lengths of stay were calculated for all patients., Results: At our institution, PA collections from patient care cover only 50% of their costs for salary and benefits. However, with PA involvement, trauma patients with orthopedic injuries were seen 205 minutes faster (P = 0.006), total Emergency Room (ER) time decreased 175 minutes (P = 0.0001), and time to surgery improved 360 minutes (P . 0.03). Operating room parameters were minimally improved, but postoperative DVT prophylaxis increased by a mean of 6.73% (P = 0.0084), postoperative antibiotic administration increased by 2.88% (P = 0.0302), and there was a 4.67% decrease in postoperative complications (P = 0.0034). Average length of stay decreased by 0.61 days (P = 0.27)., Conclusions: Although the PA's collections do not cover their costs, the indirect economic and patient care impacts are clear. By increasing emergency room pull through and decreasing times to Operating Room (OR), operative times, lengths of stay, and complications, their existence is clearly beneficial to hospitals, physicians, and patients as well., Level of Evidence: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Management of neuropathic foot ulcers in patients with diabetes (DFUs) has changed little over the past decade, and there is currently no objective method to gauge probability of successful healing. We hypothesized that studies of stem/progenitor cells (SPCs) in the early weeks of standard wound management could predict who will heal within 16 weeks. Blood and debrided wound margins were collected for 8 weeks from 100 patients undergoing weekly evaluations and treatment. SPC number and intracellular content of hypoxia-inducible factors (HIFs) were evaluated by flow cytometry and immunohistochemistry. More SPCs entered the bloodstream in the first 2 weeks of care in patients who healed (n = 37) than in those who did not (n = 63). Logistic regression demonstrated that the number of blood-borne SPCs and the cellular content of HIFs at study entry and the first-week follow-up visit predicted healing. Strong correlations were found among week-to-week assessments of blood-borne SPC HIF factors. We conclude that assays of SPCs during the first weeks of care in patients with DFUs can provide insight into how well wounds will respond and may aid with decisions on the use of adjunctive measures., (© 2016 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.)

Objectives: Fellowship-trained orthopaedic traumatologists are presumably taught skill sets leading to "best practice" outcomes and more efficient use of hospital resources. This should result in more favorable economic opportunities when compared with general orthopaedic surgeons (GOSs) providing similar clinical services. The purpose of our study was to compare the operating room utilization and financial data of traumatologists versus GOSs at a level II trauma center., Design: Retrospective review., Setting: Level II community-based trauma hospital., Patients/participants: Patients who presented to the emergency room at our institution with fractures and orthopaedic conditions requiring surgical intervention from January 1, 2010, to December 31, 2011., Intervention: Operative fracture fixation by members of our orthopaedic trauma panel, including fellowship and nontrauma fellowship-trained orthopaedic surgeons., Main Outcome Measurements: Our institutional database was queried to determine operative times, surgical supply and implant costs, and surgery labor expenses. Patients were stratified according to those treated by our trauma panel's 3 traumatologists and those treated by the 15 GOSs on our trauma panel. These 2 groups were then compared using standard statistical methods., Results: A total of 6449 orthopedic cases were identified and 2076 of these involved fracture care. One thousand one hundred ninety-nine patients were treated by traumatologists and 877 by GOSs. There was no statistical difference detected in American Society of Anesthesiologists score between trauma and nontrauma groups. Overall, the traumatologist group demonstrated significantly decreased procedure times when compared with the GOS group (55.6 vs. 75.8 minutes, P < 0.0001). In 16 of 18 most common procedure types, traumatologists were more efficient. This led to significantly decreased surgical labor costs ($381.4 vs. $484.8; P < 0.0001) and surgical supply and implant costs ($2567 vs. $3003; P < 0.0001)., Conclusions: This study demonstrates that in our community-based trauma system, fracture care provided by traumatologists results in improved utilization of hospital-based resources when compared with equivalent services provided by GOSs. Significantly decreased operative times, surgical labor expenses, and supply and implant costs by the fellowship-trained group represent enhanced control of the design, plan, execution, and monitoring of orthopaedic trauma care. Traumatologists can provide leadership recommendations for operating room efficiency in community-based orthopaedic trauma care models., Level of Evidence: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hypothesis: Surgical stabilization of displaced clavicle fractures was once considered to have rare indications. Our purpose was to present the clinical and economic effects of surgical management using data collected from operative and nonoperative patients., Methods: Our fracture database was queried from January 1, 2005, to January 1, 2010, identifying 204 patients with displaced midclavicular fractures. Radiographs and charts were reviewed, and questionnaires were distributed., Results: Operative patients had less chronic pain (6.1% vs 25.3%), less cosmetic deformity (18.2% vs 32.5%), less weakness (10.6% vs 33.7%), less loss of motion (15.2% vs 31.3%), and fewer nonunions (0% vs 4.8%). Operative patients missed fewer days of work (8.4 days vs 35.2 days) and required less assistance (3 days vs 7 days) for care at home. Mean income lost was $321.69 versus $10,506.25. Operative patients had a mean emergency department bill of $2,060.51 versus $1,871.92 and had a mean hospital bill of $8,520.30 versus $3,692.65, and anesthesia charges averaged $946.11. Operative patients required less physical therapy, and the mean physical therapy cost was $971.76 versus $1,820. Nonoperative patients required more pain medication ($43.22 vs $45.98). Overall, the cost was $12,976.94 for operative patients and $18,068.27 for nonoperative patients., Conclusions: Patients with displaced clavicle fractures benefit clinically and financially from stabilization. They have less chronic pain, less deformity, less weakness, and better range of motion. They return to work sooner, take less pain medication, and require less physical therapy. Their initial hospital bill is higher because of surgical charges but is balanced by less income loss, resulting in a cost savings of $5,091.33 in operative patients., (Copyright © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Objectives: The American Academy of Orthopedic Surgeons and the Orthopedic Trauma Association have released guidelines for the provision of orthopedic trauma services such as adequate stipends, designated operating rooms, ancillary staff, and guaranteed reimbursement for indigent care. One recommendation included a provision for hospital-based physician assistants (PAs). Given current reimbursement arrangements, PA collections for billable services may not meet their salary and benefit expenses. However, their actions may indirectly affect emergency room, operating room, and hospital reimbursement and patient care itself. The purpose of our study is to define the true impact of hospital-based PAs on orthopaedic trauma care at a level II community hospital., Design: Retrospective case series., Setting: Level II trauma center., Patients/participants: One thousand one hundred four trauma patients with orthopaedic injuries., Intervention: PA involvement., Main Outcome Measurements: Emergency room data such as triage time, time until seen by the orthopedic service, and total emergency room time was recorded. Operating room data such as time to surgery, set-up time, total operating time, and out of room time was entered as well. Charts were reviewed to determine if patients were given postoperative antibiotics and Deep Venous Thrombosis (DVT) prophylaxis. Intraoperative and postoperative complications were noted, and lengths of stay were calculated for all patients., Results: At our institution, PA collections from patient care cover only 50% of their costs for salary and benefits. However, with PA involvement, trauma patients with orthopedic injuries were seen 205 minutes faster (P = 0.006), total Emergency Room (ER) time decreased 175 minutes (P = 0.0001), and time to surgery improved 360 minutes (P > 0.03). Operating room parameters were minimally improved, but postoperative DVT prophylaxis increased by a mean of 6.73% (P = 0.0084), postoperative antibiotic administration increased by 2.88% (P = 0.0302), and there was a 4.67% decrease in postoperative complications (P = 0.0034). Average length of stay decreased by 0.61 days (P = 0.27)., Conclusions: Although the PA's collections do not cover their costs, the indirect economic and patient care impacts are clear. By increasing emergency room pull through and decreasing times to Operating Room (OR), operative times, lengths of stay, and complications, their existence is clearly beneficial to hospitals, physicians, and patients as well.

The use of multichannel array head coils in functional and structural magnetic resonance imaging (MRI) provides increased signal-to-noise ratio (SNR), higher sensitivity, and parallel imaging capabilities. However, their benefits remain to be systematically explored in the context of resting-state functional connectivity MRI (fcMRI). In this study, we compare signal detectability within and between commercially available multichannel brain coils, a 32-Channel (32Ch), and a 12-Channel (12Ch) at 3T, in a high-resolution regime to accurately map resting-state networks. We investigate whether the 32Ch coil can extract and map fcMRI more efficiently and robustly than the 12Ch coil using seed-based and graph-theory-based analyses. Our findings demonstrate that although the 12Ch coil can be used to reveal resting-state connectivity maps, the 32Ch coil provides increased detailed functional connectivity maps (using seed-based analysis) as well as increased global and local efficiency, and cost (using graph-theory-based analysis), in a number of widely reported resting-state networks. The exploration of subcortical networks, which are scarcely reported due to limitations in spatial-resolution and coil sensitivity, also proved beneficial with the 32Ch coil. Further, comparisons regarding the data acquisition time required to successfully map these networks indicated that scan time can be significantly reduced by 50% when a coil with increased number of channels (i.e., 32Ch) is used. Switching to multichannel arrays in resting-state fcMRI could, therefore, provide both detailed functional connectivity maps and acquisition time reductions, which could further benefit imaging special subject populations, such as patients or pediatrics who have less tolerance in lengthy imaging sessions.

Radiation tolerance is determined by how effectively the microstructure can remove point defects produced by irradiation. Engineered nanocrystalline SiC with a high-density of stacking faults (SFs) has significantly enhanced recombination of interstitials and vacancies, leading to self-healing of irradiation-induced defects. While single crystal SiC readily undergoes an irradiation-induced crystalline to amorphous transformation at room temperature, the nano-engineered SiC with a high-density of SFs exhibits more than an order of magnitude increase in radiation resistance. Molecular dynamics simulations of collision cascades show that the nano-layered SFs lead to enhanced mobility of interstitial Si atoms. The remarkable radiation resistance in the nano-engineered SiC is attributed to the high-density of SFs within nano-sized grain structures that significantly enhance point defect annihilation.

Objectives: To compare the results of surgical stabilization with locked plating to nonoperative care of flail chest injuries., Design: Retrospective case-control study., Setting: Level II trauma center., Patients/participants: From January 2005 to January 2010, 22 patients with flail chest treated with locked plate fixation were compared with a matched cohort of 28 nonoperatively managed patients at our institution., Intervention: Open reduction internal fixation of rib fractures with 2.7-mm locking reconstruction plates., Main Outcome Measurements: Demographic data, such as age, sex, injury severity score, number of fractures, and lung contusion severity, were recorded. Intensive care unit data concerning length of stay (LOS), tracheostomy, and ventilator days were noted. Operative data, such as time to OR, operative time, and estimated blood loss, were recorded. Hospital data, including total hospital LOS, need for reintubation, and home oxygen requirements, were documented., Results: Average follow-up period of operatively managed patients was 17.84 ± 4.51 months, with a range of 13-22 months. No case of hardware failure, hardware prominence, wound infection, or nonunion was reported. Operatively treated patients had shorter intensive care unit stays (7.59 vs. 9.68 days, P = 0.018), decreased ventilator requirements (4.14 vs. 9.68 days, P = 0.007), shorter hospital LOS (11.9 vs. 19.0 days, P = 0.006), fewer tracheostomies (4.55% vs. 39.29%, P = 0.042), less pneumonia (4.55% vs. 25%, P = 0.047), less need for reintubation (4.55% vs. 17.86%, P = 0.34), and decreased home oxygen requirements (4.55% vs. 17.86%, P = 0.034)., Conclusions: This study demonstrates the potential benefits of surgical stabilization of flail chest with locked plate fixation. When compared with case-matched controls, operatively managed patients demonstrated improved clinical outcomes. Locked plate fixation seems to be safe as no complications associated with hardware failure, plate prominence, wound infection, or nonunion were noted.

Traumatic injuries to peripheral nerves pose complex challenges to both military and civilian physicians. Treatment of nerve injuries must consider all aspects of the inherent disability. Pain control is of paramount importance. Little will be accomplished until pain is brought down to tolerable levels. Rehabilitation needs to be instituted as first-line treatment. Focus must be first placed on protection of the affected area from complications stemming from disuse and immobility and then on enhancement of strength, flexibility, sensory discrimination, and dexterity. Early intervention sets the stage for optimal physiologic and functional recovery.