Pneumothorax After Superior Plating of Clavicle Fractures: Are the Concerns Warranted?

PURPOSE

The primary goal of this study was to determine the anatomic relationship between the clavicle and the apical lung segment. The secondary goal was to determine the incidence of pneumothorax (PTX) in patients who underwent clavicle ORIF to analyze the utility of postoperative chest radiographs.

METHODS

Six hundred thirty-one patients with a midshaft clavicle fracture who underwent superior plating at a single institution were identified. Forty-two patients had a CT scan of the chest. Three points on the uninjured clavicle were defined: 2 cm from the medial end of the clavicle, the mid-point of the clavicle, and 2 cm from the lateral end of the clavicle. At each point, the distance from both the inferior cortex and the superior cortex of the clavicle to the apical lung segment was measured. All 631 patients who underwent Open Reduction and Internal Fixation had a postoperative chest radiograph to evaluate implant placement, restoration of clavicular length, and presence of PTX.

RESULTS

From the lateral end of the clavicle, the mean distance of the lung was 60.0 ± 14.9 mm (20.1 to 96.1 mm) from the inferior cortex of the clavicle. At the mid-point, the mean distance of the lung was 32.3 ± 7.2 mm (20.4 to 45.5 mm) from the inferior cortex of the clavicle. At the medial end, the mean distance of the lung was 18.0 ± 5.5 mm (8.1 to 28.9 mm) from the inferior cortex of the clavicle. A review of postoperative radiographs for all 631 patients revealed none (0%) with a postoperative iatrogenic PTX.

CONCLUSION

The risk of injury is minimal in all three zones. Postoperative chest radiographs after clavicle fracture repair to rule out PTX are unnecessary.

Thigh compartment syndrome: Outcomes in an urban level 1 trauma center

INTRODUCTION

Thigh compartment syndrome (TCS) is a rare surgical emergency associated with a high risk of morbidity with mortality rates as high as 47 %. There is sparse literature discussing the management as well as outcomes of these injuries. The purpose of this study is to review a consecutive series of patients presenting to a single urban Level 1 trauma center with TCS to identify injury characteristics, clinical presentation, and outcomes associated with this injury.

METHODS

A trauma database was queried for all patients with a diagnosis of TCS at a single level 1 urban trauma center between January 1, 2011 and December 31, 2021. Demographic and injury variables collected included age, sex, BMI, mechanism of injury, and creatine phosphokinase levels (CPK). Hospital quality measures including time from admission to surgery, length of both hospital and ICU stay, complications, and cost of care were collected. Descriptive statistics are reported as median [interquartile range] or N (percent).

RESULTS

There were 14 patients identified with a diagnosis of TCS. All were men with an average age 33.5 [23.5 - 38] years and an average BMI of 26 [22.9-28.1]. The most common cause of injury was blunt trauma (71.4 %), and the remaining 28.6 % were gunshot wound injuries. Within the cohort, 6 (42.9 %) patients sustained a femoral shaft fracture, and 4 (28.6 %) patients sustained a vascular injury. The median initial CPK of patients within this cohort was 3405 [1232-5339] and reached a peak of 5271 [3013-13,266]. The median time from admission to diagnosis was 6.8 [0-236.9] hours. The median time from admission to the operating room was 8.2 [0.6-236.9] hours, and the median number of operating room visits was 3 [2 - 6]. Five patients (35.7 %) wounds were closed with split thickness skin grafting. There were 12 (85.7 %) patients who required ICU care. The median ICU length of stay was 7.5 days [4-15]. The median hospital length of stay was 16.5 days [13.25-38.0]. The median total charges for a patient with thigh compartment syndrome was $129,159.00 [$24,768.00 - $587,152.00]. The median direct variable cost for these patients was $86,106.00 For comparison, the median direct variable cost for patients with femur fractures without TCS at this institution was $8,497.28 [$1,903.52-$21,893.13]. No patients required readmission within 60 days. There were no mortalities.

CONCLUSION

TCS is a rare and life-threatening injury associated with significant morbidity. Despite rapid diagnosis and fasciotomy, the majority of the patients have prolonged hospital courses, ICU lengths of stay, and significant costs of treatment. Providers can reference the outcomes reported in this study when caring for TCS patients.

The prone posteromedial approach to the knee revisited: a safe and effective strategy for posterior tibial plateau fractures

PURPOSE

To compare outcomes of patients with posterior tibial plateau fractures who underwent repair indirectly with an anterior approach to those who underwent direct repair with a prone "Lobenhoffer" operative approach.

METHODS

A total of 44 patients with a posterior column tibial plateau fracture that underwent repair were identified. Twenty-two patients with 22 tibial plateau fractures were fixed using a prone Lobenhoffer approach. They were compared to 22 patients treated with an indirect reduction using a supine approach for similar fracture patterns. Data collection at minimum 1 year included: patient-reported outcome scores (SMFA), patient-reported pain, knee range of motion, complications and need for reoperation. Radiographs were reviewed for knee alignment, residual depression and fracture healing.

RESULTS

All demographics were similar between the groups except BMI, which was lower in the prone group (P < 0.05). Fracture type according to age, Schatzker and three-column classification was matched between cohorts. There was no difference in outcomes including: pain, radiographic knee alignment, residual articular depression, functional outcome (SMFA), complications and need for reoperations. Knee flexion at 1 year was greater in the prone group (127.8 vs. 115.8; P = 0.018). In addition, surgical time was less in the prone group (mean 73.7 min vs. 82.3 min; P = 0.015).

CONCLUSION

The Lobenhoffer approach with direct reduction of posterior fracture fragments for complex tibial plateau fractures is an excellent option for these injuries. It allowed for faster surgery with improved ultimate knee range of motion in posterior column tibial plateau fractures.

Anesthetic Methods for Hip Fracture

PURPOSE OF REVIEW

To review the benefits, risks, and contraindications of traditional and new anesthesia approaches for hip fracture surgery and describe what is known about the impact of these approaches on postoperative outcomes.

RECENT FINDINGS

This review describes general and spinal anesthesia, peripheral nerve block techniques used for pain management, and novel, local anesthesia approaches which may provide significant benefit compared with traditional approaches by minimizing high-risk induction time and decreasing respiratory suppression and short- and long-term cognitive effects. Hip fracture surgery places a large physiologic stress on an already frail patient, and anesthesia choice plays an important role in managing risk of perioperative morbidity. New local anesthesia techniques may decrease morbidity and mortality, particularly in higher-risk patients.

Coronoid Fragment Size in Monteggia Fractures Predicts Ultimate Function

We sought to determine what effect the size of a displaced coronoid fracture fragment in Monteggia injuries has on clinical outcome. Sixty-seven patients presented to an academic medical center for operative fixation of a Monteggia fracture. Radiographs were assessed for length and height of the displaced coronoid fragment using measuring tools in our center's imaging archive system. Data were analyzed using binary logistic or linear regression, as appropriate, controlling for sex, age, and Charlson Comorbidity Index. Outcome measurements included radiographic healing, range of motion, postoperative complications, and reoperation. The cohort had a mean follow-up of 16.7 months. Mean coronoid fragment area was 362.4±155.9 mm2. Elbow range of motion decreased by 3.8° of elbow flexion (P<.001), 3.3° of elbow extension (P<.001), and 3.8° of forearm supination (P=.007) for every 1-cm2 increase in coronoid fragment area. Complications (P=.012) and reoperation (P=.036) were associated with increasing coronoid fragment area. Nonunion rate, nerve injury, and pronation range of motion were not correlated to increasing coronoid fracture fragment area (P=.777, P=.123, and P=.351, respectively). As displaced coronoid fragment size increases in Monteggia fracture patterns, elbow range of motion decreases linearly. Coronoid displacement was also associated with increased rates of postoperative complication and need for reoperation. [Orthopedics. 2024;47(1):15-21.].

Home discharge location is safest following fracture of the hip

PURPOSE

To determine the factors associated with discharge location in patients with hip fractures and whether home discharge was associated with a lower readmission and complication rate.

METHODS

Hip fracture patients who presented to our academic medical center for operative management of a hip fracture were enrolled into an IRB-approved hip fracture database. Radiographs, demographics, and injury details were recorded at the time of presentation. Patients were grouped based upon discharge disposition: home (with or without home services), acute rehabilitation facility (ARF), or sub-acute rehabilitation facility (SAR).

RESULTS

The cohorts differed in marital status, with a greater proportion of patients discharged to home being married (51.7% vs. 43.8% vs. 34.1%) (P < 0.05). Patients discharged to home were less likely to require an assistive device (P < 0.05). Patients discharged to home experienced fewer post-operative complications (P < 0.05) and had lower readmission rates (P < 0.05). Being married was associated with an increased likelihood of discharge to home (OR = 1.679, CI = 1.391-2.028, P < 0.001). Being enrolled in Medicare/Medicaid was associated with decreased odds of discharge to home (OR = 0.563, CI = 0.457-0.693, P < 0.001). Use of an assistive device was associated with decreased odds of discharge to home (OR = 0.398, CI = 0.326-0.468, P < 0.001). Increases in CCI (OR = 0.903, CI = 0.846-0.964, P = 0.002) and number of inpatient complications (OR = 0.708, CI = 0.532-0.943, P = 0.018) were associated with decreased odds of home discharge.

CONCLUSION

Hip fracture patients discharged to home were healthier and more functional at baseline, and also less likely to have had a complicated hospital course. Those discharged to home also had lower rates of readmission and post-operative complications.

LEVEL OF EVIDENCE

III.

Regional Anesthesia Is Safe and Effective for Low-Energy Tibial Plateau Fractures

The purpose of this study was to determine if the use of peripheral nerve blocks in the operative management of tibial plateau fractures is associated with improved outcomes when compared with the use of spinal and general anesthesia. Over a period of 16 years, 132 patients who underwent operative repair for a low-energy tibial plateau fracture and had at least 12 months of follow-up met the inclusion criteria and formed the basis of this study. Patients were grouped into cohorts based on the anesthetic method used during surgery: peripheral nerve block in combination with conscious sedation or general anesthesia (BA), general anesthesia alone (GA), or spinal anesthesia alone (SA). Outcomes were assessed at 3 months, 6 months, and 12 months. Length of stay was greatest in the GA cohort (P<.05), and more patients in the BA cohort were discharged to home (P<.05). Patients in the GA cohort had the highest pain scores at 3 months and 6 months (P<.05). Patients in both the SA and BA cohorts had better Short Musculoskeletal Function Assessment scores at 6 and 12 months when compared with the GA cohort (P<.05). Although knee range of motion did not differ among the three cohorts at 3 months, it did differ at 6 months and 12 months postoperatively, with those who had a preoperative nerve blockade (SA and BA) having the greatest knee range of motion (P<.05). Regional anesthesia was safe and was associated with lower pain scores in the early postoperative period and greater knee range of motion and functional outcome scores in the late postoperative period. [Orthopedics. 2023;46(6):358-364.].

Substance use and pre-hospital crash injury severity among U.S. older adults: A five-year national cross-sectional study

BACKGROUND

Alcohol and drug use (substance use) is a risk factor for crash involvement.

OBJECTIVES

To assess the association between substance use and crash injury severity among older adults and how the relationship differs by rurality/urbanicity.

METHODS

We pooled 2017-2021 cross-sectional data from the United States National Emergency Medical Service (EMS) Information System. We measured injury severity (low acuity, emergent, critical, and fatal) predicted by substance use, defined as self-reported or officer-reported alcohol and/or drug use. We controlled for age, sex, race/ethnicity, road user type, anatomical injured region, roadway crash, rurality/urbanicity, time of the day, and EMS response time. We performed a partial proportional ordinal logistic regression and reported the odds of worse injury outcomes (emergent, critical, and fatal injuries) compared to low acuity injuries, and the predicted probabilities by rurality/urbanicity.

RESULTS

Our sample consisted of 252,790 older adults (65 years and older) road users. Approximately 67%, 25%, 6%, and 1% sustained low acuity, emergent, critical, and fatal injuries, respectively. Substance use was reported in approximately 3% of the population, and this proportion did not significantly differ by rurality/urbanicity. After controlling for patient, crash, and injury characteristics, substance use was associated with 36% increased odds of worse injury severity. Compared to urban areas, the predicted probabilities of emergent, critical, and fatal injuries were higher in rural and suburban areas.

CONCLUSION

Substance use is associated with worse older adult crash injury severity and the injury severity is higher in rural and suburban areas compared to urban areas.

Tibial Plateau Fracture Surgical Care Utilizing Standardized Protocols Over Time: A Single Center's Longitudinal View

OBJECTIVE

To report on demographics, injury patterns, management strategies and outcomes of patients who sustained fractures of the tibial plateau seen at a single center over a 16-year period.

DESIGN

Prospective collection of data.Patients/ Participants: 716 patients with 725 tibia plateau fractures, were treated by one of 5 surgeons.

INTERVENTION

Treatment of tibial plateau fractures.

MAIN OUTCOME MEASUREMENTS

Outcomes were obtained at standard timepoints. Complications were recorded. Patients were stratified into 3 groups: those treated in the first 5 years, those treated in the second 5 years and those treated in the most recent 6 years.

RESULTS

608 fractures were followed for a mean 13.4 months (6-120) and 82% had a minimum 1-year follow up. Patients returned to self-reported baseline function at a consistent proportion during the 3 time periods. The average knee arc was 125 degrees (75 - 135 degrees) at latest follow up and did not differ over time. The overall complication rate following surgery was 12% and did not differ between time periods. Radiographs demonstrated excellent rates of healing and low rates of PTOA and improved articular reductions at healing (0.58 mm in group 3 compared to 0.94 mm in Group 1 and 1.12 mm in Group 2) (P<0.05).

CONCLUSION

The majority of patients regained their baseline functional status following surgical intervention and healing. Over time the ability of surgeons to achieve a more anatomic joint reduction was seen, however this did not correlate with improved functional outcomes.

LEVEL OF EVIDENCE

Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Factors Associated With the Development of a Confirmed Fracture-Related Infection

OBJECTIVES

To identify factors associated with the development of fracture-related infection (FRI) in patients who have undergone operative fixation of their fracture.

DESIGN

Retrospective study.

SETTING

Academic medical center.

PATIENTS/PARTICIPANTS

Patients with peripheral extremity long-bone fractures and shoulder and pelvic girdle fractures who underwent operative repair. This included patients who had undergone fixation inside and outside of our institution.

INTERVENTION

Chi-square, Fisher exact testing, analysis of variance (ANOVA), and t tests were used for analysis of data, as appropriate. Binomial logistic regression analysis was performed to determine risk factors of FRI.

MAIN OUTCOME MEASUREMENTS

Demographics, fracture location, injury mechanism, open wound status, and wound complication type.

RESULTS

One hundred ninety-three patients comprised the FRI cohort. Of those with confirmed signs of FRI, 36 (18.7%) had wound breakdown to bone or implant, 120 (62.1%) had a sinus track, and 170 patients (88.1%) had the confirmed presence of microorganisms in deep tissue samples obtained during operative intervention. Factors associated with development of an FRI were as follows: higher BMI; being of Black and Hispanic race; higher American Society of Anesthesiologists class; history of tobacco, alcohol, and drug use; and fractures of the lower extremity (foot, tibia, and femur/pelvis). The results of binary logistic regression demonstrated that treatment at an urban level I trauma center and drug use positively predicted the development of FRI.

CONCLUSION

Our results demonstrate that higher BMI; being of Black or Hispanic race; higher American Society of Anesthesiologists; history of tobacco, alcohol, and drug use; and fractures of the foot, tibia, and femur/pelvis are all factors associated with development of FRI.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Crosswalk between Charlson Comorbidity Index and the American Society of Anesthesiologists Physical Status Score for Geriatric Trauma Assessment

The American Society of Anesthesiologists Physical Status (ASA-PS) grade better risk stratifies geriatric trauma patients, but it is only reported in patients scheduled for surgery. The Charlson Comorbidity Index (CCI), however, is available for all patients. This study aims to create a crosswalk from the CCI to ASA-PS. Geriatric trauma cases, aged 55 years and older with both ASA-PS and CCI values (N = 4223), were used for the analysis. We assessed the relationship between CCI and ASA-PS, adjusting for age, sex, marital status, and body mass index. We reported the predicted probabilities and the receiver operating characteristics. A CCI of zero was highly predictive of ASA-PS grade 1 or 2, and a CCI of 1 or higher was highly predictive of ASA-PS grade 3 or 4. Additionally, while a CCI of 3 predicted ASA-PS grade 4, a CCI of 4 and higher exhibited greater accuracy in predicting ASA-PS grade 4. We created a formula that may accurately situate a geriatric trauma patient in the appropriate ASA-PS grade after adjusting for age, sex, marital status, and body mass index. In conclusion, ASA-PS grades can be predicted from CCI, and this may aid in generating more predictive trauma models.

Fractures of the Proximal Ulna: A Spectrum of Injuries and Outcomes

Introduction

The purpose of this study is to assess the effect of radial head/ neck injury in association with proximal ulna fractures.

Methods

Between 2006 and 2020, 107 patients presented to our academic medical center for treatment of a proximal ulna fracture and were enrolled into an IRB-approved database. Radiographs, injury details, and surgical interventions were retrospectively reviewed. Patients were classified as having an isolated proximal ulna fracture (PU), a PU fracture with an associated radial head dislocation (M-D), or a Monteggia fracture with an associated radial head fracture (M-V). Clinical and functional outcomes were assessed at follow-up to determine what differences exist between fracture patterns. Statistics were generated using Chi-squared tests for categorical variables and one-way ANOVA tests for numerical variables.

Results

While all patients ultimately healed, time to radiographic healing in the PU cohort was shorter at 3.57 ± 1.7 months when compared to the M-V cohort (5.67 ± 3.8 months) (p < 0.05). At follow-up, patients in the M-V cohort had poorer elbow pronation and supination when compared to the PU and M-D cohorts (p < 0.05). Patients within the PU cohort had fewer complications than those in the M-D and M-V cohorts (p < 0.05). No differences were found between the three cohorts in regard to rates of reoperation, non-union, wound infection, and nerve compression (p > 0.05).

Conclusion

The Monteggia fracture with a concomitant radial head/neck fracture is a more disabling injury pattern when compared to an isolated proximal ulna fracture and Monteggia fracture without an associated radial head/neck fracture.

Intra-articular fracture patterns associated with tibial shaft fractures: more than just the posterior malleolus

BACKGROUND

The association of tibial shaft fractures (TSFs) with posterior malleolar fractures is well described. The purpose of this study was to identify specific radiographic parameters that are predictive of any pattern of associated distal intra-articular fractures in TSFs.

METHODS

All TSFs presenting over a 6-year period were identified. A radiographic review of plain radiographs and CT scans included: identification of any associated ankle fracture, classification using the OTA System, measurements of the TSF obliquity angle (FOA), relative distance from distal extent of the TSF to plafond (DFP%), and presence and level of any associated fibular fractures. Patients with and without associated ankle fractures were statistically compared. Multivariate logistic regression determined independent predictors of associated ankle fractures.

RESULTS

405 TSFs in 397 patients were identified, with 145 TSFs with associated distal intra-articular fractures. There were 94 (23.2%) posterior malleolar fractures, 19 (13.1%) medial malleolar fractures, 42 (29.0%) lateral malleolar fractures involving the syndesmosis and 14 (9.7%) Chaput fragments. Multivariate regression demonstrated AO/OTA classification type 42-A1, 42-B1 or 42-C1 (OR 2.3 [95% CI 1.3-4.0]; p = 0.003), FOA greater than 45° (OR 2.7 [95% CI 1.5-4.8]; p = 0.001) and DFP% less than 33% (OR 4.1 [95% CI 2.0-9.0]; p = 0.005) were independent correlates of associated ankle fractures regardless of mechanism of injury.

CONCLUSIONS

Different patterns of intra-articular fractures beyond posterior malleolar fractures can occur in TSFs. Fracture angles greater than 45° and extent into the distal 33% of the tibial shaft are independent predictors of distal intra-articular fractures in TSFs regardless of mechanism of injury.

LEVEL OF EVIDENCE

Diagnostic Level III.

Tibial plateau fractures in the elderly have clinical outcomes similar to those in younger patients

BACKGROUND

The purpose of this study was to compare outcomes following surgical treatment of tibial plateau fractures in an elderly (≥ 65y) and non-elderly (< 65) population.

METHODS

Patients with tibial plateau fractures were prospectively followed. Patients were included if they were operatively treated, had an Injury Severity Score of < 16, and had follow-up through 12 months. Clinical, radiographic, and functional outcomes were evaluated at the 3, 6, and 12-month follow-up points.

RESULTS

Mean time to radiographic fracture union was by 4.68 and 5.26 months in young and elderly patients, respectively (p = 0.25). There was no difference in self-reported baseline SMFA (p = 0.617). SMFA scores were better in younger patients at 3 months (p = 0.031), however this did not hold when multivariate modeling controlled for other factors. There was no difference at 6 and 12 months (p = 0.475, 0.392). There was no difference in range of knee motion at 3 months. At 6 and 12 months, young patients had statistically but not clinically better range of knee motion (p = 0.045, 0.007). There were no differences in overall reoperation rates, conversion arthroplasty, post-traumatic osteoarthritis or wound complications.

CONCLUSIONS

Age greater than 65 does not appear to portend poorer outcomes after surgical repair of a tibial plateau fracture. The complication profiles are similar. Elderly and younger patients had similar function at 12 months compared to their baseline. These data suggest that age should not be a disqualifying factor when considering whether a patient with a tibial plateau fracture should be treated operatively.

Approach variation affects outcomes after operative repair of lateral tibial plateau fractures

PURPOSE

To determine if the type of approach used for treatment of lateral split-depression tibial plateau fractures affects clinical outcome and complications rate.

METHODS

This is a retrospective review of 169 patients who presented between 01/2005 and 12/2020 to a Level-I trauma center for operative management of an isolated lateral Schatzker II tibial plateau fractures (AO/OTA Type 41B3.1) treated through a single anterolateral approach: a 90-degree "L" (L), longitudinal vertical (V), or "lazy S" (S). Postoperative radiographic, clinical, and functional outcomes were assessed at 3, 6, 12 months, and beyond.

RESULTS

Average time to radiographic healing was longer in the S incision cohort (p < 0.05). Furthermore, patients within the S incision cohort developed more postoperative wound complications at follow-up when compared to those within the L and V incision cohorts (p < 0.05). Additionally, reoperation rates were greater in the S incision cohort (p < 0.05). Lastly, on physical examination of the knee, patients within the S incision cohort had significantly poorer knee range of motion (p < 0.05).

CONCLUSIONS

Our study demonstrates that skin incision type in the anterolateral approach to the proximal tibia has an association with outcomes following operative repair of tibial plateau fractures. The information from this study can be used to inform surgeons about the potential complications and long-term outcomes that patients may experience when undergoing operative repair of a tibial plateau fracture through a specific incision type.

LEVEL OF EVIDENCE

III.

Standardized Preoperative Pathways Determining Preoperative Echocardiogram Usage Continue to Improve Hip Fracture Quality

Introduction

The purpose of this study was to assess the hospital quality measures and outcomes of operative hip fracture patients before and after implementation of an anesthesiology department protocol assigning decision for a preoperative transthoracic echocardiogram (TTE) to the hospitalist co-managing physician.

Materials and Methods

Demographics, injury details, hospital quality measures, and outcomes were reviewed for a consecutive series of patients presenting to our institution with an operative hip fracture. In May of 2019, a new protocol assigning the responsibility to indicate a patient for preoperative TTE was mandated to the co-managing hospitalist at the institution. Patients were split into pre-protocol and post-protocol cohorts. Linear regression modeling and comparative analyses were conducted with a Bonferroni adjusted alpha as appropriate.

Results

Between September 2015 and June 2021, 1002 patients presented to our institution and were diagnosed with a hip fracture. Patients in the post-protocol cohort were less likely to undergo a preoperative echocardiogram, experienced a shorter time (days) to surgery, shorter length of stay, an increase in amount of home discharges, and lower complication risks for urinary tract infection and acute blood loss anemia as compared to those in the pre-protocol cohort. There were no differences seen in inpatient or 30-day mortality. Multivariable linear regression demonstrated a patient’s comorbidity profile (Charlson Comorbidity Index (CCI)) and their date of presentation (pre- or post-protocol), were both associated with (P<0.01) a patients' time to surgery.

Conclusion

A standardized preoperative work flow protocol regarding which physician evaluates and determines which patients require a preoperative TTE allows for a streamlined perioperative course for hip fracture patients. This allows for a shortened time to surgery and length of stay with an increase in home discharges and was associated with a reduced risk of common index hospitalization complications including UTI and anemia.

Value-Based Care in Orthopedic Trauma

The advent of value-based care as a component of the United States health care system is part of a broader paradigm shifting away from fee-for-service payment models in favor of alternative reimbursement incentives tied to quality and outcome metrics. Bundled care models, gainsharing agreements, and other cost containment measures, although promising, may induce unintended systemwide consequences for orthopedic trauma surgeons who often specialize in tending to costly multiply injured patients and marginalized populations. This article reviews facets of value-based care applicable to orthopedic trauma surgery with an emphasis on public health and ethical considerations for policymakers and orthopedic surgeons.

No change in outcome ten years following locking plate repair of displaced proximal humerus fractures

PURPOSE

To assess longer-term (> 5 years) function and outcome in patients treated with anatomic locking plates for proximal humerus fractures.

METHODS

This retrospective cohort study was conducted at an urban, academic level 1 trauma center and an orthopedic specialty hospital. Patients treated operatively for proximal humerus fractures with an anatomic locking plate by three orthopedic trauma surgeons and two shoulder surgeons from 2003 to 2015 were reviewed. Patient demographics and injury characteristics, disabilities of the arm, shoulder, and hand (DASH) scores, complications, secondary surgeries, and shoulder range of motion were compared at 1 year and at latest follow-up.

RESULTS

Seventy-five of 173 fractures were eligible for analysis. At a minimum 5 years and a mean of 10.0 ± 3.2 years following surgery, DASH scores did not differ from one-year compared to long-term follow-up (16.3 ± 17.4 vs. 15.1 ± 18.2, p = 0.555). Shoulder motion including: active forward flexion (145.5 vs. 151.5 degrees, p = 0.186), internal rotation (T10 vs. T9, p = 0.204), and external rotation measurements (48.4 vs. 57.9, p = 0.074) also did not differ from one year compared to long-term follow-up. By one year, all fractures had healed. After 1-year post-operatively, four patients underwent reoperation, but none for AVN or screw penetration.

CONCLUSIONS

Patient-reported functional outcome scores and shoulder range of motion are stable after one year following proximal humerus fracture fixation, and outcomes do not deteriorate thereafter. After one-year, long-term follow-up of fixed proximal humerus fractures may be unnecessary for those without symptoms.

Regional anesthesia for nonunion surgery with iliac crest bone grafting results in an increase in same day discharge

INTRODUCTION

The purpose of this study was to evaluate the outcomes of fracture nonunion repair with autogenous iliac crest bone graft (ICBG) under regional anesthesia alone or in combination with other techniques compared to other anesthesia techniques.

MATERIALS AND METHODS

Overall, 137 patients were identified who underwent ICBG as part of a repair of a long bone fracture nonunion between January 1, 2013 and October 1, 2020. Surgical and anesthetic records were reviewed to classify patients by anesthesia type. General, spinal, and regional anesthetics were used as either the primary anesthetic or as a combination of regional nerve block with general or spinal anesthesia.

RESULTS

Administration of regional anesthesia alone or in combination with general or spinal anesthesia (RA) and general or spinal anesthesia only (GS) groups differed in nonunion site distribution (p < 0.001). RA patients were discharged the same day more often than GS patients (30.9% vs 10.0%, p = 0.009) and experienced fewer postoperative complications (p = 0.021). The RA group achieved union sooner than the GS group (by 5.3 ± 3.2 months vs. by 6.8 ± 3.2 months, p = 0.006). Mean morphine equivalent dose was similar between groups (p = 0.23). Regional anesthesia use increased from 2013 to 2020, and same day discharge surgeries simultaneously increased over the same time period.

CONCLUSION

Regional anesthesia use increased in nonunion repair surgery with ICBG from 2013 to 2020. This was associated with an increase in same day discharge, sooner time to union, and decreased postoperative complications. There was not a need for increased opioid prescription in patients that underwent regional anesthesia.

Fracture-related outcome study for operatively treated tibia shaft fractures (F.R.O.S.T.): registry rationale and design

Background

Tibial shaft fractures (TSFs) are among the most common long bone injuries often resulting from high-energy trauma. To date, musculoskeletal complications such as fracture-related infection (FRI) and compromised fracture healing following fracture fixation of these injuries are still prevalent. The relatively high complication rates prove that, despite advances in modern fracture care, the management of TSFs remains a challenge even in the hands of experienced surgeons. Therefore, the Fracture-Related Outcome Study for operatively treated Tibia shaft fractures (F.R.O.S.T.) aims at creating a registry that enables data mining to gather detailed information to support future clinical decision-making regarding the management of TSF’s.

Methods

This prospective, international, multicenter, observational registry for TSFs was recently developed. Recruitment started in 2019 and is planned to take 36 months, seeking to enroll a minimum of 1000 patients. The study protocol does not influence the clinical decision-making procedure, implant choice, or surgical/imaging techniques; these are being performed as per local hospital standard of care. Data collected in this registry include injury specifics, treatment details, clinical outcomes (e.g., FRI), patient-reported outcomes, and procedure- or implant-related adverse events. The minimum follow up is 12 months.

Discussion

Although over the past decades, multiple high-quality studies have addressed individual research questions related to the outcome of TSFs, knowledge gaps remain. The scarcity of data calls for an international high-quality, population-based registry. Creating such a database could optimize strategies intended to prevent severe musculoskeletal complications. The main purpose of the F.R.O.S.T registry is to evaluate the association between different treatment strategies and patient outcomes. It will address not only operative techniques and implant materials but also perioperative preventive measures. For the first time, data concerning systemic perioperative antibiotic prophylaxis, the influence of local antimicrobials, and timing of soft-tissue coverage will be collected at an international level and correlated with standardized outcome measures in a large prospective, multicenter, observational registry for global accessibility.

Trial registration

ClinicalTrials.gov: NCT03598530.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-020-03930-x.

Femoral Periprosthetic Fracture Nonunion Management and Outcomes with Nonunion Repair and Retention of Primary Components

INTRODUCTION

Nonunion of a femoral periprosthetic fracture is a rare occurrence in orthopedic practice. Failure of a periprosthetic fracture to heal can lead to substantial disability and pain for patients as well as the potential need for component revision. Relatively little literature exists describing their management and outcome.

METHODS

Eleven patients with femoral periprosthetic fracture nonunion who presented for tertiary care were enrolled in a prospective data registry. Patients were considered to have developed nonunion following failure of progression in radiographic and clinical healing for a 6-month period. All patients were seen at standard postoperative intervals, and outcomes were recorded using the Short Musculoskeletal Function Assessment (SMFA), visual analog scale (VAS) for pain, physical examination, and radiographic examination. Preoperative radiographs were reviewed for classification.

RESULTS

Eleven patients had periprosthetic femoral fracture nonunion associated with prior hip (five patients) or knee (six patients) arthroplasty and were included in our study. Mean follow-up time was 30 months. Mean age at time of nonunion surgery was 64.5 years (range: 41.8 to 78.2 years). All patients underwent removal of previous fracture hardware at time of nonunion surgery. Ten (91%) of 11 received autogenous iliac crest bone grafting at time of nonunion surgery. Ten (91%) of the 11 patients went on to union without further intervention. Mean time to union was 7.9 months (SD: 8.0). The one patient that developed a persistent nonunion was complicated by infection requiring multiple irrigation and debridement procedures and total hip explant. The mean improvement in total SMFA score from baseline to final follow-up was 22.6 (p = 0.030). The greatest functional improvement was in the bothersome index at 28.0 (p = 0.028). The mean improvement in VAS pain score from baseline to final follow-up was 4.5 (p = 0.013).

DISCUSSION

Periprosthetic fracture nonunions can be successfully treated with operative intervention aimed at compression plating with bone graft and retention of primary components. In addition, successful periprosthetic nonunion repair improves function and pain in these patients.

Urban Cycling Expansion is Associated with an Increased Number of Clavicle Fractures

BACKGROUND

The number of individuals turning to cycling for physical activity and commuting has been expanding across the US. However, studies have demonstrated that when compared to motor vehicle accidents, cyclists in major cities have a significantly increased risk of injuries requiring hospitalizations. The purpose of this study was to assess if a correlation exists between the growing cyclist volume in a densely populated metropolitan city and prevalence of clavicle fractures requiring inpatient hospital admissions.

HYPOTHESIS

A correlation exists between the increased number of cyclists and the increasing number of clavicle fractures requiring inpatient hospital admissions.

METHODS

Patients who sustained a clavicle fracture that required an inpatient admission were identified using the New York Statewide Planning and Research Cooperative System (SPARCS). The location of hospital admission was screened using New York City (NYC) hospital county codes, as only clavicle fractures presenting to NYC hospitals were included in the analysis. This study was exempt from Institutional Review Board (IRB) approval. Public transportation data was available through the Department of Transportation (DOT) and The Decennial Census. These databases are publicly available and are performed to assess if New Yorkers are using cycling as a mode of transportation. The cycling data included the following information in a given year: the number of people in NYC who use a bicycle as their primary mode of commuting to work, the number of daily cycling trips, total bicycle protected bike lane mileage, midtown Manhattan cycling counts and East River Bridge cycling counts. Spearman's correlation analysis was conducted between the numbers of patients with clavicle fractures per year and the described data for that specific year. Additionally, the number of bicycle-share program miles traveled per month and total number of cycling trips that month were obtained from the public bicycle-sharing program database from June 2013 through June 2015. Spearman's correlation analysis was conducted between the numbers of patients with clavicle fractures per month and total bicycle-sharing miles and trips traveled per month.

RESULTS

The increasing daily cycling trips in NYC has a strong correlation with the increasing number of clavicle fractures in NYC (rs = .979, p < 0.001). The increasing use of a bicycle as transportation to work has a strong positive correlation with the increasing number of clavicle fractures in NYC (rs = .988, p < 0.001). There was a strong positive correlation between the mileage of bicycle lanes in NYC and the number of clavicle fractures (rs = .867, p = 0.001). A strong positive correlation exists between NYC clavicle fracture number and public bicycle-sharing miles (rs = .819, p < 0.001) and trips (rs = .811, p < 0.001).

CONCLUSION

There are many physical benefits to cycling. Cycling, as a means of transportation, has been encouraged to decrease CO2 emissions from vehicular transportation. These benefits do not come without risks, as this study shows a correlation between increased cycling and clavicle fractures.

CLINICAL RELEVANCE

Physicians and public health officials should be aware of the dangers of cycling in major cities in order to create safer routes for this environmentally beneficial route of transportation.

4118Cisplatin therapy as a risk factor for incident atrial fibrillation

Background

Although aging is a major contributor to the rising epidemic of atrial fibrillation (AF), increased numbers of cancer survivors who suffer from chemotherapy and radiotherapy mediated cardiovascular disease also appear to be especially vulnerable to developing the arrhythmia. Currently, little is known about the long-term risk of AF in patients treated with these two treatment modalities for cancer.

Purpose

To define the incidence and prevalence of AF in a thoracic tumour cohort following radiotherapy and chemotherapy.

Methods

We conducted a retrospective study from the electronic health records (EHR) of patients who had a primary tumour of the breast and lung. Patients with AF, radiotherapy or chemotherapy prior to cancer diagnosis were excluded. All patients were followed for incident AF until last censoring or death using a validated AF algorithm (positive predictive value 96%). Radiation oncology treatment reports were reviewed and chemotherapy data was extracted from the EHR and manually reviewed for 43 chemotherapeutic agents.

Results

In the tumour registry, 17,402 patients were identified by histological and pathological reports. We examined 3,336 patients with a thoracic tumour diagnosis (breast and lung) with a mean age of 62.7±12.5 (SD) years. The AF incident rate for breast and lung cancer was 1.2 and 13.5 cases per every 100 persons with a cumulative rate of 2.49 and 0.67 respectively. We observed an overall AF prevalence of 3.4% and 7.4% in the breast and lung cohorts respectively. The average follow-up duration was 4.69 years (0.0–17.8 years) in breast cancer and 1.36 years (0.0–13.9 years) in lung cancer patients. A Cox regression model revealed no association between radiotherapy and AF in either cancer type (breast: P=0.18 and lung: P=0.16). However, patients who received cisplatin had 4-fold increased risk of developing AF after covariate adjustment (HR = 4.22, 95% CI: 0.10–17.85, P=0.05).

Conclusions

We show for the first time in a large thoracic tumour registry and using the EHR that patients treated with cisplatin were more likely to develop AF. Additional studies are needed to validate our findings and to further investigate the underlying mechanisms of these cardiotoxic effects.

Acknowledgement/Funding

This work was supported in part by grants from the AHA 17MCPRP33420153 (Brandon Chalazan) and NIH/NHLBI R01 HL092217 and HL138737 (Dawood Darbar).

Wound-Healing Issues Following Rotational Ankle Fracture Surgery: Predictors and Local Management Options

Background. The incidence and risk factors of wound-healing complications following rotational ankle fracture surgery are well documented in the literature. However, there is a paucity regarding management options following these complications. The goal of this study was to provide a descriptive analysis of one surgeon's experience managing wound complications in patients who have undergone ankle fracture surgery. Methods. A total of 215 patients who were operatively treated for an unstable ankle were retrospectively identified. Patient demographics, medical histories, initial injury characteristics, surgical interventions, and clinical follow-up were collected. Twenty-five of these patients developed postoperative wound problems. Results. Of the original cohort of 215 patients, 25 (11.6%) developed wound-healing complications. Their average age was 53.6 ± 18.0 years; there were 12 males (48.0%). Connective tissue/inflammatory disease (odds ratio [OR] 3.9), cardiovascular disease (OR 3.6), and active smoking (OR 3.3) were associated with an increased likelihood of developing postoperative wound complications. With regard to injuries, open fractures (OR 17.9) had the highest likelihood of developing postoperative complications, followed by type 44-C (OR 2.8) and trimalleolar fractures (OR 2.0). Conclusion. Wound complications following open treatment of ankle fractures occurred with an incidence of 11.6% in this series, of which only about half required operative intervention. A third of wounds were managed by orthopaedics in conjunction with plastic surgery. Levels of Evidence: Level III: Retrospective comparative study.

Final outcomes of radial nerve palsy associated with humeral shaft fracture and nonunion

Background

Little evidence regarding the extent of recovery of radial nerve lesions with associated humerus trauma exists. The aim of this study is to examine the incidence and resolution of types of radial nerve palsy (RNP) in operative and nonoperative humeral shaft fracture populations.

Materials and Methods

Radial nerve lesions were identified as complete (RNPc), which included motor and sensory loss, and incomplete (RNPi), which included sensory-only lesions. Charts were reviewed for treatment type, radial nerve status, RNP resolution time, and follow-up time. Descriptive statistics were used to document incidence of RNP and time to resolution. Independent-samples t-test was used to determine significant differences between RNP resolution time in operative and nonoperative cohorts.

Results

A total of 175 patients (77 operative, 98 nonoperative) with diaphyseal humeral shaft injury between 2007 and 2016 were identified and treated. Seventeen out of 77 (22.1%) patients treated operatively were diagnosed preoperatively with a radial nerve lesion. Two (2.6%) patients developed secondary RNPc postoperatively. Eight out of 98 (8.2%) patients presented with RNP postinjury for nonoperatively treated humeral shaft fracture. All patients who presented with either RNPc, RNPi, or iatrogenic RNP had complete resolution of their RNP. No statistically significant difference was found in recovery time when comparing the operative versus nonoperative RNPc, operative versus nonoperative RNPi, or RNPc versus RNPi patient groups.

Conclusions

All 27 (100%) patients presenting with or developing radial nerve palsy in our study recovered. No patient required further surgery for radial nerve palsy. Radial nerve exploration in conjunction with open reduction and internal fixation (ORIF) appears to facilitate speedier resolution of RNP when directly compared with observation in nonoperative cases, although not statistically significantly so. These findings provide surgeons valuable information they can share with patients who sustain radial nerve injury with associated humerus shaft fracture or nonunion.

Level of evidence

Level III treatment study.

Complications and unplanned outcomes following operative treatment of tibial plateau fractures

INTRODUCTION

The operative management of tibial plateau fractures is challenging and post-operative complications do occur. The purpose of this study was three-fold. 1). To report complications and unplanned outcomes in patients who had sustained tibial plateau fractures and were operatively managed 2). To report predictors of these post-operative events 3). To report if differences in clinical outcomes exist in patients who sustained a post-operative event.

METHODS

Over 11 years, all tibial plateau fractures were prospectively followed. Clinical outcomes were assessed using the validated Short Musculoskeletal Functional Assessment (SMFA) score. Demographics, initial injury characteristics, surgical details and post-operative events were prospectively recorded. Student's t-tests were used for continuous variables and chi-squared analysis was used for categorical variables. Binary logistic regression and multivariate linear regression were conducted for independent predictors of post-operative events and complications and functional outcomes, respectively.

RESULTS

275 patients with 279 tibial plateau fractures were included in our analysis. Ten patients (3.6%) sustained a deep infection. Six patients (2.2%) developed a superficial infection. One patient (0.4%) presented with early implant failure. Two patients (0.7%) developed a fracture nonunion. Eight patients (2.9%) developed a venous thromboembolism. Seventeen patients (6.2%) went on to re-operation for symptomatic implant removal. Nine patients (3.3%) underwent a lysis of adhesions procedure. Univariate analysis demonstrated bicondylar tibial plateau fractures (P<0.001), Moore fracture-dislocations (P=0.005), open fractures (P=0.022), and compartment syndrome (P=0.001) to be associated with post-operative complications and unplanned outcomes. Long-term functional outcomes were worse among patients who developed a post-operative complication or unplanned outcome (P=0.031).

CONCLUSION

Orthopaedic trauma surgeons should be aware of complications and unplanned outcomes following operatively managed tibial plateau fractures, along with having the knowledge of factors that are associated with development of post-operative events.

Short-Term Outcomes Following Hip Fractures in Patients at Least 100 Years Old

BACKGROUND

The number of hip fractures is rising as life expectancy increases. As such, the number of centenarians sustaining these fractures is also increasing. The purpose of this study was to determine whether patients who are ≥100 years old and sustain a hip fracture fare worse in the hospital than those who are younger.

METHODS

Using a large database, the New York Statewide Planning and Research Cooperative System (SPARCS), we identified patients who were ≥65 years old and had been treated for a hip fracture over a 12-year period. Data on demographics, comorbidities, and treatment were collected. Three cohorts were established: patients who were 65 to 80 years old, 81 to 99 years old, and ≥100 years old (centenarians). Outcome measures included hospital length of stay, estimated total costs, and in-hospital mortality rates.

RESULTS

A total of 168,087 patients with a hip fracture were identified, and 1,150 (0.7%) of them had sustained the fracture when they were ≥100 years old. Centenarians incurred costs and had lengths of stay that were similar to those of younger patients. Despite the similarities, centenarians were found to have a significantly higher in-hospital mortality rate than the younger populations (7.4% compared with 4.4% for those 81 to 99 years old and 2.6% for those 65 to 80 years old; p < 0.01). Male sex and an increasing number of medical comorbidities were found to predict in-hospital mortality for centenarians sustaining extracapsular hip fractures. No significant predictors of in-hospital mortality were identified for centenarians who sustained femoral neck fractures. An increased time to surgery did not influence the odds of in-hospital mortality.

CONCLUSIONS

Centenarians had increased in-hospital mortality, but the remaining short-term outcomes were comparable with those for the younger cohorts with similar fracture patterns. For this extremely elderly population, time to surgery does not appear to affect short-term mortality rates, suggesting a potential benefit to preoperative optimization.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of malrotation following intramedullary nailing in a femoral shaft fracture model: Can a 3D c-arm improve accuracy?

INTRODUCTION

Difficulty determining anatomic rotation following intramedullary (IM) nailing of the femur continues to be problematic for surgeons. Clinical exam and fluoroscopic imaging of the hip and knee have been used to estimate femoral version, but are inaccurate. We hypothesize that 3D c-arm imaging can be used to accurately measure femoral version following IM nailing of femur fractures to prevent rotational malreduction.

METHODS

A midshaft osteotomy was created in a femur Sawbone to simulate a transverse diaphyseal fracture. An intramedullary (IM) nail was inserted into the Sawbone femur without locking screws or cephalomedullary fixation. A goniometer was used to simulate four femoral version situations after IM nailing: 20° retroversion, 0° version, 15° anteversion, and 30° anteversion. In each simulated position, 3D c-arm imaging and, for comparison purposes, perfect lateral radiographs of the knee and hip were performed. The femoral version of each simulated 3D and fluoroscopic case was measured and the results were tabulated.

RESULTS

The measured version from the 3D c-arm images was 22.25° retroversion, 0.66° anteversion, 19.53° anteversion, and 25.15° anteversion for the simulated cases of 20° retroversion, 0° version, 15° anteversion, and 30° anteversion, respectively. The lateral fluoroscopic views were measured to be 9.66° retroversion, 12.12° anteversion, 20.91° anteversion, and 18.77° anteversion for the simulated cases, respectively.

CONCLUSION

This study demonstrates the utility of a novel intraoperative method to evaluate femur rotational malreduction following IM nailing. The use of 3D c-arm imaging to measure femoral version offers accuracy and reproducibility.

Distal patellar tendon avulsion in association with high-energy knee trauma: A case series and review of the literature

BACKGROUND

Patellar tendon rupture is rare in the general population. Typically, failure occurs proximally or at the mid-substance. Distal avulsion from the tibial tubercle in adults is rare and not well described in the orthopedic literature.

METHODS

We present the largest series of patients with distal patellar tendon injury with associated multi-ligamentous disruption of the knee. A series of six patients with distal patellar tendon avulsion were identified at a single institution. The cases were reviewed and are presented.

RESULTS

Each case of distal patellar tendon rupture was associated with high-energy trauma to the knee. There was multi-ligamentous disruption in all cases, associated tibial plateau fracture in one case, and a compartment syndrome diagnosed in another. We propose that distal patellar tendon avulsion is a distinct pathology of the extensor mechanism in healthy adults. When present, it should prompt clinicians to assess patients for occult knee dislocation, monitor their neurovascular status, and obtain an MRI to evaluate for associated multi-ligamentous injury.

CONCLUSION

We propose a modification to the Schenk classification to include extensor mechanism injury to help guide steps of operative intervention.

Functional outcome after proximal humerus fracture fixation : understanding the risk factors

The purpose is to identify risk factors of functional outcome following proximal humerus open reduction and internal fixation. Patients treated for proximal humerus fractures with open reduction and internal fixation were enrolled in a prospective data registry. Patients were evaluated for function using the Disability of the Arm, Shoulder and Hand score for 12 months and as available beyond 12 months. Univariate analyses were conducted to identify variables associated with functional outcome. Significant variables were included in a multivariate regression predicting functional outcome. Demographics and minimum of 12 month follow-up were available for 129 patients (75%). Multiple regression demonstrated postoperative complication (B=8.515 p=0.045), education level (B=-6.269p<0.0005), age (B=0.241p=0.049) and Charlson Comorbidity Index (B=6.578, p=0.001) were all significant predictors of functional outcome. Orthopaedic surgeons can use education level, comorbidities, age, and postoperative complication information to screen patients for worse outcomes, establish expectations, and guide care.

One-Pot Synthesis of 2,4,5-Trisubstituted Imidazoles via [2 + 2 + 1] Cycloannulation of 1,3-Bishet(aryl)-monothio-1,3-diketones, α-Substituted Methylamines and Sodium Nitrite through α-Nitrosation of Enaminones

An efficient one-pot synthesis of a series of diversely functionalized trisubstituted 4(5)het(aroyl)-2,5(4)-het(aryl)/alkylimidazoles from readily available 1,3-bishet(aryl)monothio-1,3-diketones has been reported. This novel sequential one-pot, three step protocol, wherein three new carbon nitrogen bonds are formed in contiguous fashion, involves in situ generation of enaminones by reaction of monothio-1,3-diketones with α-substituted methylamines, followed by their α-nitrosation with sodium nitrite and subsequent base mediated intramolecular heterocyclization of the resulting α-hydroxyiminoimines to trisubstituted imidazoles in high yields under mild conditions. These newly prepared 4(5)-het(aroyl)-5(4)-het(aryl)/alkylimidazoles are shown to exist as tautomeric mixture, however, their subsequent alkylation with methyl iodide in the presence of potassium carbonate affords 1-N-methy-2,5-bishet(aryl)-4-het(aroyl)imidazoles in highly regioselective fashion in most of the cases. Synthesis of few 4(5)-(2-hydroxyphenyl)-2,5(4)-substituted imidazoles, which are known to be good coordinating ligands, has also been reported. A probable mechanism for the formation of these imidazoles from hydroxyiminoimine intermediates has also been suggested.

A Review of the Definitive Treatment of Pelvic Fractures

Pelvic ring injuries can result in significant morbidity and mortality. New techniques, technologies, and research have led to the development of various algorithms to guide the initial diagnosis and management of these injuries. These include treatment with antibiotics and operative debridement in the case of open fractures and temporary stabilization in certain cases with sheets, binders, or external fixators. Yet even after successful completion of the initial treatment phase, identifying and implementing the optimal definitive treatment of pelvic ring injuries remains a challenge. Various classification schemes have been proposed and contribute in different ways to an understanding of pelvic ring injuries. The current paper will review the definitive management of pelvic ring injuries, ultimately using the Young and Burgess classification as a guide, with a focus on current practice and the supporting evidence.

Identification of urinary proteins potentially associated with diabetic kidney disease

Diabetic nephropathy (DN) is the most common cause of chronic kidney disease. Although several parameters are used to evaluate renal damage, in many instances, there is no pathological change until damage is already advanced. Mass spectrometry-based proteomics is a novel tool to identify newer diagnostic markers. To identify urinary proteins associated with renal complications in diabetes, we collected urine samples from 10 type 2 diabetes patients each with normoalbuminuria, micro- and macro-albuminuria and compared their urinary proteome with that of 10 healthy individuals. Urinary proteins were concentrated, depleted of albumin and five other abundant plasma proteins and in-gel trypsin digested after prefractionation on sodium dodecyl sulfate polyacrylamide gel electrophoresis. The peptides were analyzed using a nanoflow reverse phase liquid chromatography system coupled to linear trap quadrupole-Orbitrap mass spectrometer. We identified large number of proteins in each group, of which many were exclusively present in individual patient groups. A total of 53 proteins were common in all patients but were absent in the controls. The majority of the proteins were functionally binding, biologically involved in metabolic processes, and showed enrichment of alternative complement and blood coagulation pathways. In addition to identifying reported proteins such as α2-HS-glycoprotein and Vitamin D binding protein, we detected novel proteins such as CD59, extracellular matrix protein 1 (ECM1), factor H, and myoglobin in the urine of macroalbuminuria patients. ECM1 and factor H are known to influence mesangial cell proliferation, and CD59 causes microvascular damage by influencing membrane attack complex deposition, suggestive their biological relevance to DN. Thus, we have developed a proteome database where various proteins exclusively present in the patients may be further investigated for their role as stage-specific markers and possible therapeutic targets.

Current Practices Regarding Perioperative Management of Patients With Fracture on Antiplatelet Therapy: A Survey of Orthopedic Surgeons

OBJECTIVE

There continues to be controversy over whether operative delay is necessary for patients on antiplatelet therapy, particularly for elderly patients with hip fractures. This study sought to assess current clinical practices of orthopedic surgeons regarding perioperative management of these patients.

METHODS

A 12-question, Web-based survey was distributed to orthopedic surgeons via e-mail. Questions regarding timing of surgery assumed patients were on antiplatelet therapy and assessed attitudes toward emergent and nonemergent orthopedic cases as well as operative delay for specific closed fracture types. Responses were compared using unpaired, 2-tailed Student t tests for continuous variables and Pearson chi-square tests with odds ratios (ORs) and 95% confidence intervals (CIs) for categorical variables. Statistical significance was defined as a P value <.05.

RESULTS

Overall 67 orthopedic surgeons responded. Fifty-two percent (n = 35) of the respondents described their practice as academic. Thirty-nine percent (n = 25) of the surgeons indicated that no delay was acceptable for urgent but nonemergent surgery, and 78% (n = 50) reported no delay for emergent surgery was acceptable. Sixty-eight percent (n = 46) of respondents felt patients on antiplatelet therapy with closed hip fractures did not require operative delay. Surgeons who opted for surgical delay in hip fractures were more likely to delay surgery in other lower extremity fracture types (OR = 16.4, 95% CI 4.48-60.61, P < .001). Sixty-four percent (n = 41) of the surgeons indicated there was no protocol in place at their institution.

CONCLUSIONS

There continues to be wide variability among orthopedic surgeons with regard to management of patients with fracture on antiplatelet therapy. Over a quarter of surgeons continue to opt for surgical delay in patients with hip fracture. This survey highlights the need to formulate and better disseminate practice management guidelines for patients with fracture on antiplatelet therapy, particularly given the aging population in the United States.

Age-related percutaneous penetration part 2: effect of age on dermatopharmacokinetics and overview of transdermal products

Transdermal drug delivery allows for a constant rate of drug administration and prolonged action, which can be beneficial to elderly patients who are often polymedicated. Several studies have compared dermatopharmacokinetics in the young and elderly with conflicting results. Despite the potential limitations of age-related changes in skin factors and cutaneous metabolism, marketed transdermal products generally do not report age-related differences in pharmacokinetics. This overview discusses the current data, summarizes marketed product findings and highlights the importance of further studies to evaluate age-related dermatopharmacokinetics.

Age-related percutaneous penetration part 1: skin factors

Changes in the skin that occur in the elderly may put them at increased risk for altered percutaneous penetration from pharmacotherapy along with potential adverse effects. Skin factors that may have a role in age-related percutaneous penetration include blood flow, pH, skin thickness, hair and pore density, and the content and structure of proteins, glycosaminoglycans (GAGs), water, and lipids. Each factor is examined as a function of increasing age along with its potential impact on percutaneous penetration. Additionally, topical drugs that successfully overcome the barrier function of the skin can still fall victim to cutaneous metabolism, thereby producing metabolites that may have increased or decreased activity. This overview discusses the current data and highlights the importance of further studies to evaluate the impact of skin factors in age-related percutaneous penetration.

Primary cutaneous follicle center lymphoma in the setting of chronic lymphocytic leukemia

Primary cutaneous malignancies arising in association with chronic lymphocytic leukemia (CLL) are notable for their atypical clinical and histological presentation. We report a 69-year-old man with a 17-year history of CLL who presented for evaluation of a well-defined red to violaceous nodule with a central depressed scar on the left lower extremity. Microscopic examination of a punch biopsy revealed an infiltrate of predominantly small lymphocytes with scattered large, atypical epithelioid cells. Immunohistochemical stains revealed diffuse positive staining of the lesional cells with CD20+ and bcl-6+ and focal positive staining with bcl-2+ (negative CD10 and CD23), findings which, in conjunction with the histology, were most compatible with a diagnosis of primary cutaneous follicle center lymphoma (PCFCL). A review of the clinical charts revealed several prior biopsies with varied diagnoses. In light of the most recent biopsy findings, all previous biopsies were re-reviewed and interpreted as PCFCL arising in the setting of CLL. Features contributing to the diagnostic conundrum in this case included an atypical clinical and histological presentation, lack of pertinent clinical history and multiple presentations at different institutions.

Do postsurgical interventions optimize ultimate scar cosmesis

Keloids and other scars are different manifestations of the normal wound healing process. If located in visible areas, scars may have a psychological impact that could affect the quality of life of the scar-bearing population. Good preoperatory planning including hiding incisions in natural anatomical landmarks or placing them parallel to relaxed skin tension lines are among the techniques used to improve the cosmesis of scars. Once a prominent or noticeable scar has developed, multiple therapeutic modalities can be applied including surgical excision, although high recurrence rates precludes its use as monotherapy. Several advanced surgical correction techniques including Z-plasty and W-plasty may be useful in repositioning scars. Other modalities that have been reported to improve scar cosmesis include cryosurgery, radiotherapy, lasers, and skin substitute grafts. Adjuvant postsurgical treatment modalities have reduced dramatically the recurrence rates associated with the removal of the scar. In this review of the literature the authors discuss evidence based data related to the abovementioned modalities and other topical and intralesional therapies including occlusion, compression, silicone, corticosteroids, interferons, imiquimod, resiquimod, tacrolimus, 5-fluorouracil, retinoids, as well as the role of several over-the-counter agents such as onion extract, vitamin E and the combination of hydrocortisone, vitamin E and silicone. Finally, they address newer modalities including vascular endothelial growth factor inhibitor, transforming growth factor-3, interleukin-10, mannose-6-phosphate, UVA-1, narrowband UVB, intense pulsed light and photodynamic therapy. Ultimately, the decision of choosing the most appropriate postexcisional management treatment should be taken by physicians on a case-by-case basis in order to obtain the best cosmetically acceptable results.

Prolonged exercise induces angiogenesis and increases cerebral blood volume in primary motor cortex of the rat

Plastic changes in motor cortex capillary structure and function were examined in three separate experiments in adult rats following prolonged exercise. The first two experiments employed T-two-star (T(2)*)-weighted and flow-alternating inversion recovery (FAIR) functional magnetic resonance imaging to assess chronic changes in blood volume and flow as a result of exercise. The third experiment used an antibody against the CD61 integrin expressed on developing capillaries to determine if motor cortex capillaries undergo structural modifications. In experiment 1, T(2)*-weighted images of forelimb regions of motor cortex were obtained following 30 days of either repetitive activity on a running wheel or relative inactivity. The proton signal intensity was markedly reduced in the motor cortex of exercised animals compared with that of controls. This reduction was not attributable to alterations of vascular iron levels. These results are therefore most consistent with increased capillary perfusion or blood volume of forelimb regions of motor cortex. FAIR images acquired during experiment 2 under normocapnic and hypercapnic conditions indicated that resting cerebral blood flow was not altered under normal conditions but was elevated in response to high levels of CO(2), suggesting that prolonged exercise increases the size of a capillary reserve. Finally, the immunohistological data indicated that exercise induces robust growth of capillaries (angiogenesis) within 30 days from the onset of the exercise regimen. Analysis of other regions failed to find any changes in perfusion or capillary structure suggesting that this motor activity-induced plasticity may be specific to motor cortex.These data indicate that capillary growth occurs in motor areas of the cerebral cortex as a robust adaptation to prolonged motor activity. In addition to capillary growth, the vascular system also experiences heightened flow under conditions of activation. These changes are chronic and observable even in the anesthetized animal and are measurable using noninvasive techniques.

Cytotoxic T lymphocyte antigen 4 gene polymorphism confers susceptibility to type 1 diabetes in Japanese children: analysis of association with HLA genotypes and autoantibodies

OBJECTIVE

Although the polymorphisms of the cytotoxic T lymphocyte antigen 4 (CTLA4) gene have been shown to be associated with Type 1 diabetes in Caucasians, some conflicting results have been reported among subjects of different ethnic backgrounds. We examined a CTLA4 polymorphism and its relationship to human leucocyte antigen (HLA) genotypes and autoantibodies for glutamic acid decarboxylase 65 (GAD65) and IA-2 in Japanese children with Type 1 diabetes.

SUBJECTS AND MEASUREMENTS

The study group consisted of 125 childhood-onset Japanese subjects (50 males, 75 females) with Type 1 diabetes. The CTLA4 A/G polymorphism at position 49 was analysed using a PCR-restriction fragment length polymorphism (PCR-RFLP) method. The HLA-DRB1 and DQB1 genotypes were defined by DNA analysis using PCR-sequence-specific oligonucleotide (PCR-SSO) probes. The GAD65 autoantibody (GAD65Ab) and IA-2 autoantibody (IA-2Ab) titres were measured using radioimmunoassay.

RESULTS

The distribution of genotype frequencies differs between subjects with Type 1 diabetes (GG: 46%, AG: 50%, AA: 5%) and controls (GG: 39%, AG: 44%, AA: 17%) (P < 0.01). The frequency of the G allele is higher in the diabetes group than in the controls (P < 0.05). When the subjects were subdivided according to HLA genotype, the two major HLA high-risk groups, with DR9-DQ9 and DR4-DQ4, that are unique to Japanese populations showed no difference in their CTLA4 polymorphism frequencies. Although no association between the CTLA4 polymorphism and the prevalence of GAD65Ab was found, CTLA4 GG subjects that had been newly diagnosed (< 9 months) had significantly higher levels of autoantibodies than AG subjects (P < 0.01). The prevalence and titres of IA-2Ab were not associated with the CTLA4 polymorphism.

CONCLUSIONS

The CTLA4 gene might confer a susceptibility to childhood-onset Type 1 diabetes in the Japanese population. The association between this CTLA4 polymorphism and the HLA genotype was similar for both major groups with HLA high-risk alleles. CTLA4 might contribute to the humoral immune response to GAD in newly diagnosed subjects.

Recurrence of sellar and suprasellar tumors in children treated with hGH--relation to immunohistochemical study on GH receptor

PURPOSE

GH replacement therapy is required in the majority of children with GH deficiency after treatment of sellar and suprasellar tumors. Owing to the high cell proliferative ability of human GH (hGH), its influence on tumor recurrence has been debated. We retrospectively studied the immunohistochemical expression of the GH receptor in various tumor tissues, in order to investigate the relation between tumor recurrence and hGH replacement.

METHODS

GH replacement therapy was performed in 25 patients (8 boys and 17 girls) after the treatment. Tumor recurrence was noted in 4 patients (craniopharyngioma: 2 patients, pilocytic astrocytoma and germinoma: 1 each). Immunohistochemical study of GH receptor in tumor tissue was carried out in those recurrent and recurrence-free cases, by using MAb 263 as a primary antibody.

RESULTS

Two patients with recurrent craniopharyngioma were positive for MAb 263, but 1 recurrence-free patient was negative. Patients with pilocytic astrocytoma (recurrent and recurrence-free: 1 each) were all positive. Five patients with germinoma (1 with recurrence and 4 without recurrence) were all negative.

CONCLUSION

In the patients with craniopharyngioma treated with GH, a positive immunohistochemical expression of GH receptor in tumor tissue may indicate a high probability of recurrence. In our cases, GH receptor was positive in astrocytomas and negative in germinomas, with or without recurrence. It is therefore speculated that each brain tumor may have its specificity in GH receptor expression.

Long-term follow-up results of adult patients with acute lymphocytic leukemia or lymphoblastic lymphoma treated with short-term, alternating non-cross-resistant chemotherapy: Japan Clinical Oncology Group Study 8702. Lymphoma Study Group

BACKGROUND

Patients with acute lymphocytic leukemia (ALL) and those with lymphoblastic lymphoma (LBL) have overlapping clinical and immunophenotypic features and they have been treated with the same or very similar chemotherapy regimens. The goal of this multi-institutional phase II trial was to evaluate the therapeutic efficacy of a short-term, six-drug chemotherapy regimen for adult patients with untreated ALL or LBL.

METHODS

Forty-six eligible patients, 41 with ALL and five with LBL, were treated with a short-term (planned total therapy duration; 36-38 weeks), simplified chemotherapy program; two courses of VEPA-L (vincristine, cyclophosphamide, prednisolone, doxorubicin, I-asparaginase plus intrathecal methotrexate and prednisolone) followed by four courses of M-VEPA (methotrexate plus VEPA), without the traditional maintenance therapy using daily 6-mercaptopurine and weekly methotrexate.

RESULTS

Thirty-six (78%; 95% confidence interval 64-89%) of the 46 eligible patients achieved complete remission (CR). Among the 36 patients who achieved CR, four (11%) died of treatment complications, 26 (72%) relapsed and six (17%) remain alive in continuous CR. The median survival for all 46 eligible patients is 14 months and the median disease-free survival (DFS) for the 36 patients who achieved CR is 11 months. The estimate of the proportion of survival at 7 years of all 46 eligible patients is 15% at a median follow-up time of 96 months and that of DFS of the 36 patients achieving CR is 17% at a median follow-up time of 93 months. Subgroup analysis showed that an elevated serum C-reactive protein (CRP) level, age of 30 years or older, the presence of B-symptom and T-cell phenotype were likely to be associated with shortened survival. Although the observed CR rate (78%) is within the range of satisfaction, the long-term survival rate (15%) is inferior to those of published programs incorporating maintenance therapy.

CONCLUSIONS

A fraction of adult patients with ALL or LBL are curable with a short-term, six-drug chemotherapy regimen. However, this simplified therapy of shorter duration cannot be recommended.

Experiences with duodenum preserving pancreatectomy

According to the principle of surgery for chronic pancreatitis the preservation of pylorus, duodenum or distal part of common bile duct gives the benefit of more physiological intervention. 2 patients with duodenum preserving pancreatectomy are presented. The operation was carried out for chronic pancreatitis. Both patients had jaundice and needed T drainage. Both patients suffered from very severe malnutrition with cachectic condition adding severe pain. None of them proved to be malignant by the frozen section. Previous diabetes, severe chronic inflammation of the whole pancreas, destruction of the pancreatic ductal system and cysts helped the decision-making for ablation of pancreas with preservation of duodenum which seems organ saving procedure. In comparison with the Whipple operation the duodenum-preserving pancreatectomy spares the patient a gastrectomy, a duodenectomy and a resection of distal common bile duct.

Targeting dendrimer-chelates to tumors and tumor cells expressing the high-affinity folate receptor

RATIONALE AND OBJECTIVES

The authors developed a new method for delivering contrast agents to tumors and tumor cells. Gadolinium complexes of folate-conjugated dendrimer-chelates increased the longitudinal relaxation rate of tumor cells expressing the high-affinity folate receptor, hFR. The coupling of folate to polymeric chelates, composed of a dendrimer backbone, targets these chelates to endogenous folate binding proteins. These proteins exist in both the serum of patients with cancer and on the cell surface of many human cancers of epithelial origin.

METHODS

The authors attached folic acid to a generation four ammonia core polyamidoamine dendrimer. The folate-dendrimer was reacted with 2-(4-isothiocyanatobenzyl)-6-methyl-diethylenetriaminepentaacetic acid to form the polymeric chelate f-PAMAM-TU-DTPA. For fluorescent studies, the generation four dendrimer was reacted with fluorescein-5-isothiocyanate and carboxytetramethylrhodamine succinimidyl ester, followed by capping the remaining amines with succinic anhydride.

RESULTS

The study results show that cells accumulate the folate-conjugated dendrimer in a receptor specific manner. Tumor cells expressing the high-affinity folate receptor showed a 650% increase in the mean fluorescence. This increase occurred with a rapid rise to 325%, followed by a slow increase to 650%. It required both the expression of the hFR and the coupling of folic acid to the dendrimer. Excess free folic acid inhibited the binding of the folate conjugated polymer. Fluorescent microscopic study showed that the folate-conjugated dendrimer binds to the cell surface and is accumulated within the cells. Treatment of tumor cells that express the hFR with gadolinium complexes of the folate-conjugated polymeric chelate increases the longitudinal relaxation rate by 110%. This increase was inhibited by an excess of free folic acid.

CONCLUSIONS

These data demonstrate that folate-conjugated magnetic resonance imaging contrast agents represent a promising new approach to tumor targeting.

Association of HLA-DR, DQ genotype with different beta-cell functions at IDDM diagnosis in Japanese children

Japanese IDDM patients have been demonstrated to have unique and different HLA associations from white patients. To elucidate the effect of HLA-associated genetic factors on the clinical heterogeneity of IDDM in Japanese people, HLA-DRB1, DQA1, and DQB1 genotypes in 88 childhood-onset Japanese IDDM patients were examined by polymerase chain reaction-sequence-specific oligonucleotide (PCR-SSO) or sequence-specific primers (SSP). Of the 88 IDDM patients, 26 (29.5%) had DRB1*0405-DQA1*0302-DQB1*0401/X (DR4-DQ4/X), 38 (43.2%) had DRB1*0901-DQA1*0302-DQB1*0303/X (DR9-DQ9/X), and 9 (10.2%) were DR4/9-DQ4/9 heterozygous in the present study (X does not contain protective alleles). Clinical heterogeneity such as age distribution at onset, prevalence and serum level of anti-GAD antibodies (GADAb), and residual pancreatic beta-cell function after diagnosis were compared between patients with HLA-DR4-DQ4 and DR9-DQ9. The frequency of DR9-DQ9 genotype was significantly higher in the younger (0-10 years) than in the older (11-16 years) age-group of onset, but the frequency of DR4-DQ4 was higher in the older (11-16 years) age-group. Although no association of DR-DQ genotypes with the prevalence and serum level of GADAb was found among newly diagnosed patients, long-standing DR9-DQ9 patients had significantly higher levels of GADAb than those with DR4-DQ4. While no difference in time course of serum C-peptide (CPR) levels was detected between GADAb+ and GADAb- patients, a remarkable difference was demonstrated between DR9-DQ9 and DR4-DQ4 patients. The residual pancreatic beta-cell function was retained more in patients with DR4-DQ4 than in those with DR9-DQ9 at diagnosis through 12-18 months after diagnosis. These results suggest that the DR9-DQ9 genotype may induce stronger autoimmune destructive response (T-helper 1 function) against target beta-cells than the DR4-DQ4 genotype does. Our findings may warrant further studies on the association of diabetogenic autoimmune response with HLA class II molecules and contribute to a clarification of interracial differences in HLA-encoded susceptibility to IDDM.

Clinical significance and time course of antibodies to glutamic acid decarboxylase in Japanese children with type I (insulin-dependent) diabetes mellitus

Although anti-glutamic acid decarboxylase antibodies (GADAb) have been reported to be a useful diagnostic and predictive marker of insulin-dependent diabetes mellitus (IDDM, type 1 DM) in Caucasians, a precise analysis of GADAb in Japanese children has not been reported. We examined the clinical significance and time course of GADAb in Japanese IDDM children, who have different genetic backgrounds from Caucasians. Twenty-three of 34 (67.6%) sera from recent-onset (< 6 months) IDDM, and 16 of 49 (32.7%) sera from long-standing (> or = 2 years) IDDM patients were positive for GADAb. This prevalence of GADAb in IDDM patients was significantly higher than in normal controls and the other groups including non-insulin-dependent DM, autoimmune thyroid disease and congenital hypothyroidism, and was also significantly higher in recent-onset than in long-standing IDDM. Time course analysis suggested that autoimmune response against GAD could follow different courses in individual cases after the initiation of insulin therapy. The incidence of GADAb was significantly higher in females than in males in the older age group (11-15 years). Other clinical features including residual pancreatic beta-cell function after diagnosis were demonstrated to be similar between GADAb-positive and -negative patients. In conclusion, this study using the newly established radioimmunoassay (RIA) for GADAb revealed a high prevalence of autoimmune reactivity to GAD in Japanese IDDM children. These results, using this RIA procedure, might assist in laying the groundwork for future trials of immunomodulation therapy for IDDM in Japan.