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Determine the etiologies of non-traumatic extremity compartment syndrome (NTECS), understand the demographics of NTECS patients, describe their diagnostic workup and treatment, and establish their rate and cause of in-hospital mortality. This is a retrospective cohort study of all patients diagnosed with NTECS at two level 1 trauma centers between January 2006 and December 2019. Data pertaining to the etiology of NTECS, patient demographics, diagnostic and treatment modalities, and in-hospital mortality were collected from electronic medical records. A total of 572 patients were included in this study with an average age of 54±18 years. The etiologies of NTECS were categorized into one of seven groups: 233 hypercoagulable state, 113 found-down secondary to substance use, 68 hypocoaguable state, 58 perioperative positioning, 55 shock, 30 infection, and 15 intravenous/intraosseous (IV/IO) infiltration. Approximately 13 % of patients underwent a skin graft or flap procedures, while 13 % of patients required an extremity amputation. The in-hospital mortality was highest in patients who developed NTECS due to shock (58 %). The average in hospital-mortality for all NTECS etiologies was 20 %. While uncommon, many etiologies of NTECS exist and often manifest insidiously. 13% of patients who develop NTECS will require a skin graft / flap, or extremity amputation. 20 % of patients who develop NTECS die during their hospitalization. High clinical suspicion and future research in this field are necessary to improve clinical outcomes for these patients. Level IV: Retrospective review., Competing Interests: Declaration of competing interest None, (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: To determine if the results of the OXYGEN trial changed using an "as-treated" approach instead of the original "intention-to-treat" approach. The multi-center randomized controlled OXYGEN trial aimed to determine the effectiveness of high FiO2 in decreasing infection rates for high-risk tibial plateau, tibial pilon, and calcaneus fractures., Methods: A secondary analysis of a multi-center randomized controlled trial conducted at 29 US trauma centers was performed. A total of 1231 patients aged 18-80 years with tibial plateau, tibial pilon, or calcaneus fractures thought to be at elevated risk of infection were enrolled. Patients were randomly assigned to receive inspired oxygen at a concentration of 80 % FiO2 (treatment) or 30 % FiO2 (control). Adherence was defined using two different criteria. Criterion 1 required at least 80 % of the surgery time ≤40 % FiO2 for the control group or ≥70 % FiO2 for the treatment group. Criterion 2 required at least 80 % of surgery time within 20-40 % (control) or 70-90 % FiO2 (treatment). The primary outcome was surgical site infection (SSI) within 182 days of definitive fracture fixation. Secondary outcomes were deep and superficial surgical site infections within 90, 182, and 365 days of definitive fixation., Results: Under Criterion 1, the primary outcome occurred in 7 % (38/523) and 10 % (49/471) of patients in the treatment and control groups, respectively (p = 0.10). Deep infection occurred in 30 (6 %) treatment and 30 (6 %) control patients (p = 0.75). Superficial infection occurred in 9 (2 %) treatment and 20 (4 %) control patients (RR, 0.41; p = 0.03). Using Criterion 2, the primary outcome occurred in 7 % (36/498) of treatment and 10 % (48/468) of control patients (p = 0.12). Deep infection occurred in 28 (6 %) treatment and 29 (6 %) control patients (p = 0.81). Superficial infection occurred in 9 (2 %) treatment and 20 (4.3 %) control patients (RR = 0.43; p = 0.03)., Conclusions: When re-analyzing based on which patients actually received high or control levels of perioperative oxygen fraction, the results are somewhat consistent with the original "intent-to-treat" analysis. Specifically, high perioperative oxygen lowered the risk of superficial SSI but did not affect deep infections., Competing Interests: Declaration of competing interest No conflicts specific to this manuscript were declared., (Copyright © 2024. Published by Elsevier Ltd.)

Intimate partner violence is an overlooked, underestimated, and under reported cause of musculoskeletal injury. This literature review aims to provide an updated overview of the prevalence of IPV, along with the identification and screening tools available to orthopaedic surgeons for early detection and intervention. Additionally, the review discusses the importance of training in medical education for orthopaedic surgeons to effectively recognize and address IPV. Through an analysis of current research and best practices, this review highlights the need for increased awareness, education, and collaboration among healthcare professionals to effectively address IPV as a public health issue., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

This literature review examines the impact of orthopaedic trauma on patient mental health. It focuses on patient outcomes, available resources, and healthcare provider knowledge and education. Orthopaedic trauma represents a significant physical and psychological burden for patients, often resulting in long-term disability, pain, and functional limitations. Understanding the impact of orthopaedic trauma on patient mental health is crucial for improving patient care, and optimizing recovery and rehabilitation outcomes. In this review, we synthesize the findings of empirical studies over the past decade to explore the current understanding of mental health outcomes in patients with orthopaedic trauma. Through this analysis, we identify gaps in existing research, as well as potential avenues for improving patient care and mental health support for patients with severe orthopaedic injuries. Our review reveals the pressing need for collaboration between healthcare providers, mental health professionals, and social support systems to ensure comprehensive mental care for patients with traumatic orthopaedic injuries., (© 2024. The Author(s).)

Objectives: Acute orthopedic traumatic musculoskeletal injuries are prevalent, costly, and often lead to persistent pain and functional limitations. Psychological risk factors (eg, pain catastrophizing and anxiety) exacerbate these outcomes but are often overlooked in acute orthopedic care. Addressing gaps in current treatment approaches, this mixed-methods pilot study explored the use of a therapeutic virtual reality (VR; RelieVRx ), integrating principles of mindfulness and cognitive-behavioral therapy, for pain self-management at home following orthopedic injury., Methods: We enrolled 10 adults with acute orthopedic injuries and elevated pain catastrophizing or pain anxiety from Level 1 Trauma Clinics within the Mass General Brigham health care system. Participants completed daily RelieVRx sessions at home for 8 weeks, which included pain education, relaxation, mindfulness, games, and dynamic breathing biofeedback. Primary outcomes were a priori feasibility, appropriateness, acceptability, satisfaction, and safety. Secondary outcomes were pre-post measures of pain, physical function, sleep, depression, and hypothesized mechanisms (pain self-efficacy, mindfulness, and coping)., Results: The VR and study procedures met or exceeded all benchmarks. We observed preliminary improvements in pain, physical functioning, sleep, depression, and mechanisms. Qualitative exit interviews confirmed high satisfaction with RelieVRx and yielded recommendations for promoting VR-based trials with orthopedic patients., Discussion: The results support a larger randomized clinical trial of RelieVRx versus a sham placebo control to replicate the findings and explore mechanisms. There is potential for self-guided VR to promote evidence-based pain management strategies and address the critical mental health care gap for patients following acute orthopedic injuries., Competing Interests: This study was funded by the Cathedral Fund and support was provided by Applied VR. The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Periprosthetic joint infection remains a major problem. The bactericidal efficacy of commercial irrigation solutions for the treatment of infection is not well established in the presence of porous titanium (Ti) implants. This study compared the in vitro efficacy of five irrigation solutions on infected three-dimensional-printed porous Ti discs., Methods: Titanium discs (2 × 4 mm, 400, 700, and 1,000 μm) were infected with S. aureus (1 × 10 6 colony-forming unit/mL) and incubated for 3 hours or 3 days to create acute or chronic infection with biofilm. Discs were irrigated with saline, antibiotic, or antiseptic solutions, then repeatedly sonicated. Sonicates were cultured for bacterial quantification. Statistical analyses were performed using one-way analysis of variance (ANOVA), followed by Tukey-Kramer post hoc testing (P < .05 significance). Biofilms were visualized by scanning electron microscopy., Results: Saline irrigation was ineffective in both groups. In acute infections with 400 μm pores, differences were found with saline versus solution #3 (P = .015) and #4 (P = .015). Solution #4 had the lowest bacterial counts for all pore sizes. For biofilm, irrigation with saline, solutions #1, #2, and #3 inadequately cleared bacteria in all pore sizes. Lower remaining concentrations were observed in #4 with 400μm pores compared to saline (P = .06) and #2 (P = .039). The scanning electron microscopy showed a reduction of biofilm in samples washed with #4., Conclusions: Irrigation of infected porous Ti discs with saline, solutions #1 and #2 failed to reduce the bacterial load. The 400 μm discs consistently had more bacteria despite irrigation, highlighting the difficulty of removing bacteria from small pores. Solutions #3 and #4 reduced bacteria acutely, but only #4 demonstrated efficacy in clearing biofilm compared to saline. These results should be considered when treating periprosthetic joint infection in the presence of porous components and the potential presence of biofilm., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Patient-reported outcome measures (PROMs) are widely used in medicine. As older adults, who may rely on a proxy caregiver for answers due to cognitive impairment, are representing an increasing share of the traumatically injured patient population, proxy-reported outcome measures (proxROMs) offer a valuable alternative source of patient-centered information although its association with PROMs is unclear. The objective of this scoping review is to discuss all available literature comparing PROM and proxROMs in adult patients with musculoskeletal trauma to guide future research in this field., Methods: The PRISMA extension for Scoping Reviews was used to guide this review. MEDLINE, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials were searched without date limit for articles comparing PROM and proxROMs in setting of musculoskeletal trauma. Abstract and full-text screening were performed by two independent reviewers. Variables included study details, patient and proxy characteristics, and reported findings on agreement between PROMs and proxROMs., Results: Of 574 unique records screened, 13 were included. Patient and proxy characteristics varied greatly, while patients' cognitive status and type of proxy perspective were poorly addressed. 18 different PROMs were evaluated, mostly reporting on physical functioning and disability (nine, 50%) or quality of life (six, 33%). Injury- and proxy-specific tools were rare, and psychometric properties of PROMs were often not described. Studies reported moderate to good agreement between PROMs and proxROMs. There is less agreement on subjective outcome measures (e.g., depression score) compared to observable items, and proxy bias results in in worse outcomes compared to patient self-reports., Conclusion: Current literature, though limited, demonstrates moderate to good agreement between injured patients' self- and proxy-reports. Future studies should be mindful of current guidelines on proxy reporting when developing their studies and consider including neglected populations such as cognitively impaired patients to improve clinical validity., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Introduction: Elder abuse is a prevalent, though often overlooked and underreported, cause of musculoskeletal injury in the elderly population. The purpose of this review is to provide an updated overview of the prevalence of elder abuse, its association with musculoskeletal injuries, and the available resources to aid orthopaedic surgeons in early detection and intervention., Significance: Improved training on this topic is needed throughout the medical education of orthopaedic surgeons to effectively recognize and address elder abuse. Our findings reveal an urgent need for increased awareness, education, and collaboration among healthcare professionals to address this significant public health concern. As the aging population continues to grow, understanding the connection between elder abuse and musculoskeletal injuries is essential for providing comprehensive care to older adults., Results: This review offers practical recommendations for identifying individuals at risk of elder abuse and outlines strategies for intervention. Indicators of abuse range from obvious signs like dirty clothes, neglect, and unattended injuries from falls, to more subtle cues requiring careful observation and questioning, such as mental health symptoms and family histories of abuse., Conclusion: By shedding light on this often-overlooked issue, this review advocates for a proactive approach to identifying and addressing elder abuse to safeguard the well-being and quality of life of older individuals., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Introduction: Case volumes of trauma centers and surgeons influence clinical outcomes following orthopaedic trauma surgery. This study quantifies surgical volume benchmarks for Orthopaedic Trauma Association (OTA)-accredited fellowship training in the United States., Methods: This was a retrospective cross-sectional study of orthopaedic trauma fellows graduating between 2018 and 2019 to 2022-2023. Case volume percentiles were calculated across categories and variability defined as the fold-difference between 90th and 10th percentiles. Temporal trends were assessed with linear regression., Results: 446 orthopaedic trauma fellows were included in this study. Mean reported case volume increased from 898 ± 245 in 2018-2019 to 974 ± 329 in 2022-2023 (P = 0.066). Mean case volume was 924 over the study period and mostly consisted of other (418 cases, 45 %), subtrochanteric/intertrochanteric femoral neck (84 cases, 9 %), open fracture debridement (72 cases, 8 %), pelvic ring disruption / fracture (55 cases, 6 %), acetabular fracture (41 cases, 4 %), tibial shaft fracture (39 cases, 4 %), and femoral shaft fracture (38 cases, 4 %) cases. Overall variability in total reported case volume was 2.0. Variability was greatest in distal radius fracture (14.8), amputation (9.5), fasciotomy (8.0), and proximal humerus repair (5.0)., Conclusion: Graduates from OTA-accredited fellowship training perform 924 cases on average, which exceeds the current minimum requirement of 600 cases. Case volume benchmarks can assist trainees and faculty align training goals with fellowship program strengths. More research is needed to determine evidence-based case minimum requirements for core competency training in orthopaedic trauma surgery., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Clinical guidelines for performing total joint arthroplasty (TJA) have not been uniformly adopted in practice because research has suggested that they may foster inequities in surgical access, potentially disadvantaging minority sociodemographic groups. The aim of this study was to assess whether undergoing TJA without meeting clinical guidelines affects complication risk and leads to disparities in postoperative outcomes., Methods: This retrospective cohort study evaluated the records of 11,611 adult patients who underwent primary TJA from January 1, 2010, to December 31, 2020, at an academic hospital network. Based on self-reported race and ethnicity, 89.5% of patients were White, 3.5% were Black, 2.9% were Hispanic, 1.3% were Asian, and 2.8% were classified as other. Patients met institutional guidelines for undergoing TJA if they had a hemoglobin A1c of <8.0% and a body mass index of <40 kg/m 2 and were not currently smoking. A logistic regression model was utilized to identify factors associated with complications, and a mixed-effects model was utilized to identify factors associated with not meeting guidelines for undergoing TJA., Results: During the study period, 11% (1,274) of the 11,611 adults who underwent primary TJA did not meet clinical guidelines. Compared with the group who met guidelines, the group who did not had higher proportions of Black patients (3.2% versus 6.0%; p < 0.001) and Hispanic patients (2.7% versus 4.6%; p < 0.001). An increased risk of not meeting guidelines at the time of surgery was demonstrated among Black patients (odds ratio [OR], 1.60 [95% confidence interval (CI), 1.22 to 2.10]; p = 0.001) and patients insured by Medicaid (OR, 1.75 [95% CI, 1.26 to 2.44]; p = 0.001) or Medicare (OR, 1.22 [95% CI, 1.06 to 1.41]; p = 0.007). Patients who did not meet guidelines had a higher risk of reoperation than those who met guidelines (7.7% [98] versus 5.9% [615]; p = 0.017), including a higher risk of infection-related reoperation (3.1% [40] versus 1.4% [147]; p < 0.001)., Conclusions: We found that patients who underwent TJA despite not meeting institutional preoperative criteria had a higher risk of postoperative complications. These patients were more likely to be from racial and ethnic minority groups, to have a lower socioeconomic status, and to have Medicare or Medicaid insurance. These findings underscore the need for surgery-related shared decision-making that is informed by evidence-based guidelines in order to reduce complication burden., Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H941 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Objectives: Little is known about the post-operative functional outcomes of severely frail femur fracture patients, with previous studies focusing on complications and mortality. This study investigated patient- or proxy-reported outcomes after femur fracture surgery in older adult patients with severe frailty. Methods: This was a retrospective cross-sectional study of older adult (>70 years) patients with severe frailty (defined by a Comprehensive Geriatric Assessment-based Frailty Index (FI-CGA) ≥ 0.40), who underwent femur fracture surgery at a Level 1 Trauma Center. Patients or their proxy (i.e., close relative) reported mobility, psychosocial, and functional outcomes at least 1-year after surgery. Results: Thirty-seven predominantly female (76%) patients with a median age of 85 years (IQR 79-92), and a median FI-CGA of 0.48 (IQR 0.43-0.54) were included. Eleven patients (30%) regained pre-fracture levels of ambulation, with twenty-six patients (70%) able to walk with or without assistance. The majority of patients (76%) were able to have meaningful conversations. Of the patients, 54% of them experienced no to minimal pain, while 8% still experienced a lot of pain. Functional independence varied, as follows: five patients (14%) could bathe themselves; nine patients (25%) could dress themselves; fourteen patients (39%) could toilet independently; and seventeen patients (47%) transferred out of a (wheel)chair independently. Conclusions: Despite the high risk of mortality and perioperative complications, many of the most severely frail patients with surgically treated femur fractures regain the ability to ambulate and live with a moderate degree of independence. This information can help healthcare providers to better inform these patients and their families of the role of surgical treatment during goals of care discussions.

Over the past several decades, there has been a growing prevalence of entomology-themed outreach events, which seek to educate the public about insects and other arthropods, fostering a greater appreciation and understanding of these often misunderstood organisms. In 2016, a comparative analysis was initiated to identify science institutions across the United States engaged in providing annual entomology-themed outreach events to the public. Utilizing literature reviews and online searches, several science institutions were identified and subsequently contacted to partake in a survey regarding their events. The survey received a response rate of 93%. Results from the survey offered valuable insights into these entomology-themed outreach events, including records of attendance, event structures, funding sources, popular exhibits, and the impacts on attendees, hosting institutions, and local communities. While the majority of these events have remained in place since the survey, many have experienced significant disruptions due to the COVID-19 pandemic, prompting some to adapt to innovative online formats and virtual experiences. Despite these challenges, the commitment to entomological outreach continues today, highlighting the resilience and adaptability of the entomology community.

Objectives: To compare outcomes in patients on direct oral anticoagulants (DOACs) treated within 48 hours of last preoperative dose with those with surgical delays >48 hours., Design: Retrospective cohort study., Setting: Three academic Level 1 trauma centers., Patient Selection Criteria: Patients 65 years of age or older on DOACs before hip fracture treated between 2010 and 2018. Patients were excluded if last DOAC dose was >24 hours before admission, patient suffered from polytrauma, and/or delay to surgery was not attributed to DOAC., Outcome Measures and Comparisons: Primary outcome measures were the postoperative complication rate as determined by diagnosis of deep venous thrombosis or pulmonary embolus, wound breakdown, drainage, or infection. Secondary outcomes included transfusion requirement, perioperative bleeding, length of stay, reoperation rates, readmission rates, and mortality., Results: Two hundred five patients were included in this study, with a mean cohort age of 81.9 years (65-100 years), 64% were (132/205) female, and a mean Charlson Comorbidity Index of 6.4 (2-20). No significant difference was observed among age, sex, Charlson Comorbidity Index, or fracture pattern between cohorts (P > 0.05 for all comparisons). Seventy-one patients had surgery <48 hours after final preoperative DOAC dose; 134 patients had surgery >48 hours after. No significant difference in complication rate between the 2 cohorts was observed (P = 0.30). Patients with delayed surgical management were more likely to require transfusion (OR 2.39, 95% CI, 1.05-5.44; P = 0.04). Patients with early surgical management had significantly shorter lengths of stay (5.9 vs. 7.6 days, P < 0.005). There was no difference in estimated blood loss, anemia, reoperations, readmissions, 90-day mortality, or 1-year mortality (P > 0.05 for all comparisons)., Conclusions: Geriatric patients with hip fracture who underwent surgical management within 48 hours of their last preoperative DOAC dose required less transfusions and had decreased length of stay, with comparable mortality and complication rates with patients with surgery delayed beyond 48 hours. Providers should consider early intervention in this population rather than adherence to elective procedure guidelines., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Microwave-to-optics transduction is emerging as a vital technology for scaling quantum computers and quantum networks. To establish useful entanglement links between qubit processing units, several key conditions must be simultaneously met: the transducer must add less than a single quantum of input-referred noise and operate with high efficiency, as well as large bandwidth and high repetition rate. Here we present a design for an integrated transducer based on a planar superconducting resonator coupled to a silicon photonic cavity through a mechanical oscillator made of lithium niobate on silicon. We experimentally demonstrate its performance with a transduction efficiency of 0.9% with 1 μW of continuous optical power and a spectral bandwidth of 14.8 MHz. With short optical pulses, we measure the added noise that is limited to a few photons, with a repetition rate of up to 100 kHz. Our device directly couples to a 50 Ω transmission line and can be scaled to a large number of transducers on a single chip, laying the foundations for distributed quantum computing., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

Objectives: To compare clinical and radiographic outcomes after retrograde intramedullary nailing (rIMN) versus locked plating (LP) of "extreme distal" periprosthetic femur fractures, defined as those that contact or extend distal to the anterior flange., Design: Retrospective review., Setting: Eight academic level I trauma centers., Patient Selection Criteria: Adult patients with periprosthetic distal femur fractures at or distal to the anterior flange (OTA/AO 33B-C[VB1]) treated with rIMN or LP., Outcome Measures and Comparisons: The primary outcome was reoperation to promote healing or to treat infection (reoperation for elective removal of symptomatic hardware was excluded from this analysis). Secondary outcomes included nonunion, delayed union, fixation failure, infection, overall reoperation rate, distal femoral alignment, and ambulatory status at final follow-up. Outcomes were compared between patients treated with rIMN or LP., Results: Seventy-one patients treated with rIMN and 224 patients treated with LP were included. The rIMN group had fewer points of fixation in the distal segment (rIMN: 3.5 ± 1.1 vs. LP: 6.0 ± 1.1, P < 0.001) and more patients who were allowed to weight-bear as tolerated immediately postoperatively (rIMN: 45%; LP: 9%, P < 0.01). Reoperation to promote union and/or treat infection was 8% in the rIMN group and 16% in the LP group ( P = 0.122). There were no significant differences in nonunion ( P > 0.999), delayed union ( P = 0.079), fixation failure ( P > 0.999), infection ( P = 0.084), or overall reoperation rate ( P > 0.999). Significantly more patients in the rIMN group were ambulatory without assistive devices at final follow-up (rIMN: 35%, LP: 18%, P = 0.008)., Conclusions: rIMN of extreme distal periprosthetic femur fractures has similar complication rates compared with LP, with a possible advantage of earlier return to weight-bearing. Surgeons can consider this treatment strategy in all fractures with stable implants and amenable prosthesis geometry, even extreme distal fractures., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture)., Methods: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications., Results: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups., Conclusions: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.)., (Copyright © 2024 Massachusetts Medical Society.)

Bicondylar tibial plateau fractures are technically demanding fractures that have a high complication rate. We sought to review the recent literature with the aim to summarize the development of new classification systems that may enhance the surgeon's understanding of the fracture pattern and injury. We highlight the best methods for infection control and touch on new innovative solutions using 3D printer models and augmented mixed reality to provide potentially personalized solutions for each specific fracture configuration., Competing Interests: None, (2024 © BY THE ARCHIVES OF BONE AND JOINT SURGERY.)

Background: Rodent models are commonly employed to validate preclinical disease models through the evaluation of postoperative behavior and allodynia. Our study investigates the dynamic interplay between pain and functional recovery in the context of traumatic osteotomy and surgical repair. Specifically, we established a rat model of tibial osteotomy, followed by internal fixation using a 5-hole Y-plate with 4 screws, to explore the hypothesis that histological bone healing is closely associated with functional recovery., Objective: Our primary objective was to assess the correlation between bone healing and functional outcomes in a rat model of tibial osteotomy and plate fixation., Methods: Seventeen male Sprague-Dawley rats underwent a metaphyseal transverse osteotomy of the proximal tibia, simulating a fracture-like injury. The resultant bone defect was meticulously repaired by realigning and stabilizing the bone surfaces with the Y-plate. To comprehensively assess recovery and healing, we performed quantitative and qualitative evaluations at 2, 4, 6, and 8 weeks post-surgery. Evaluation methods included micro-CT imaging, X-ray analysis, and histological examination to monitor bone defect healing. Concurrently, we employed video recording and gait analysis to evaluate functional recovery, encompassing parameters such as temporal symmetry, hindlimb duty factor imbalance, phase dispersion, and toe spread., Results: Our findings revealed complete healing of the bone defect at 8 weeks, as confirmed by micro-CT and histological assessments. Specifically, micro-CT data showed a decline in fracture volume over time, indicating progressive healing. Histological examination demonstrated the formation of new trabecular bone and the resolution of inflammation. Importantly, specific gait analysis parameters exhibited longitudinal changes consistent with bone healing. Hindlimb duty factor imbalance, hindlimb temporal symmetry, and phase dispersion correlated strongly with the healing process, emphasizing the direct link between bone healing and functional outcomes., Conclusions: The establishment of this tibia osteotomy model underscores the association between bone healing and functional outcomes, emphasizing the feasibility of monitoring postoperative recovery using endpoint measurements. Our overarching objective is to employ this model for assessing the local efficacy of drug delivery devices in ameliorating post-surgical pain and enhancing functional recovery., (© 2023. The Author(s).)

Background: Decision-making with regard to the treatment of humeral shaft fractures remains under debate. The cost-effectiveness of these treatment options has yet to be established. This study aims to compare the cost-effectiveness of operative treatment with that of nonoperative treatment of humeral shaft fractures., Methods: We developed a decision tree for treatment options. Surgical costs included the ambulatory surgical fee, physician fee, anesthesia fee, and, in the sensitivity analysis, lost wages during recovery. We used the Current Procedural Terminology codes from the American Board of Orthopaedic Surgery to determine physician fees via the U.S. Centers for Medicare & Medicaid Services database. The anesthesia fee was obtained from the national conversion factor and mean operative time for included procedures. We obtained data on mean wages from the U.S. Bureau of Labor and data on weeks missed from a similar study. We reported functional data via the Disabilities of the Arm, Shoulder and Hand (DASH) scores obtained from existing literature. We used rollback analysis and Monte Carlo simulation to determine the cost-effectiveness of each treatment option, presented in dollars per meaningful change in DASH score, utilizing a $50,000 willingness-to-pay (WTP) threshold., Results: The cost per meaningful change in DASH score for operative treatment was $18,857.97 at the 6-month follow-up and $25,756.36 at the 1-year follow-up, by Monte Carlo simulation. Wage loss-inclusive models revealed values that fall even farther below the WTP threshold, making operative management the more cost-effective treatment option compared with nonoperative treatment in both settings. With an upward variation of the nonoperative union rate to 84.17% in the wage-exclusive model and 89.43% in the wage-inclusive model, nonoperative treatment instead became more cost-effective., Conclusions: Operative management was cost-effective at both 6 months and 1 year, compared with nonoperative treatment, in both models. Operative treatment was found to be even more cost-effective with loss of wages considered, suggesting that an earlier return to baseline function and, thus, return to work are important considerations in making operative treatment the more cost-effective option., Level of Evidence: Economic and Decision Analysis Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H629 )., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Abstract: ➢ Natural language processing with large language models is a subdivision of artificial intelligence (AI) that extracts meaning from text with use of linguistic rules, statistics, and machine learning to generate appropriate text responses. Its utilization in medicine and in the field of orthopaedic surgery is rapidly growing.➢ Large language models can be utilized in generating scientific manuscript texts of a publishable quality; however, they suffer from AI hallucinations, in which untruths or half-truths are stated with misleading confidence. Their use raises considerable concerns regarding the potential for research misconduct and for hallucinations to insert misinformation into the clinical literature.➢ Current editorial processes are insufficient for identifying the involvement of large language models in manuscripts. Academic publishing must adapt to encourage safe use of these tools by establishing clear guidelines for their use, which should be adopted across the orthopaedic literature, and by implementing additional steps in the editorial screening process to identify the use of these tools in submitted manuscripts., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H601 )., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Bicondylar tibial plateau fractures are complex injuries that commonly require surgical repair. Long-term clinical outcome has been associated with discrepancies in leg alignment, instability and condylar width abnormalities. While intuitive, the degree of articular damage at time of injury has not been linked to outcomes in patients with bicondylar tibial plateau fractures. The aim of this study was to quantify percentage of articular surface cross sectional area disruption and assess for correlation between the degree of articular injury and patient reported physical function., Methods: Retrospective cohort study at two level 1 trauma centers. 57 consecutive patients undergoing surgical repair for bicondylar tibial plateau fractures between 2013 and 2016., Main Outcome Measure: Preoperative CT scans were reviewed, and the percentage of articular surface disruption cross sectional area was calculated. PROMIS ® scores were collected from patients at a minimum of 2 years., Results: 57 patients with an average age of 58 ± 14.3 years were included. The average PROMIS ® score was 45.5. There was a correlation between percentage of articular surface disruption and total PROMIS ® scores (0.4, CI: 0.2-0.5, p = .007) and the physical function of the PROMIS ® score (0.4, CI: 0.2-0.6, p < .001)., Conclusion: Our method for calculating articular surface disruption on CT is a simple, reproducible and accurate method for assessing the degree of articular damage in patients with bicondylar tibial plateau fractures. We found that the percentage of cross-sectional articular surface disruption correlates with patient reported outcomes and physical function., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: To evaluate the quality of evidence published in geriatric traumatology, to investigate how many studies include patients with cognitive impairment, and to investigate which methods are used to determine cognitive impairment., Data Sources: A search was conducted in PubMed for all publications in English in 154 selected journals between 01/01/2017 and 01/01/2020., Study Selection: Clinical studies investigating patients 65 years of age and older with fractures in the appendicular skeleton or pelvis were included., Data Extraction: Two independent reviewers performed full-text screening and data extraction for all articles., Data Synthesis: A comparative analysis was performed for prospective cohort studies and RCTs. The results are discussed in a narrative review., Conclusions: A total of 2711 publications were screened for eligibility, and after exclusion, a total of 723 articles were included. There is a focus on retrospective studies investigating mortality and complications. Studies are often small in sample size, and there are relatively few prospective studies, RCT studies, patient-reported outcomes, and quality of life. Patients with cognitive impairment are selectively excluded from clinical studies, and no consensus exists on how cognitive impairment is diagnosed. This review identified pitfalls and provides recommendations to navigate these issues for future studies. Many studies exclude cognitively impaired patients, which may result in selection bias and inability to extrapolate results. The lack of use of objective measures to define cognitive impairment and lack appropriate outcome measures for the cognitively impaired is an important issue that needs to be addressed in future research., Competing Interests: The authors declare no possible conflicts of interest, including financial, consultant, institutional, and other relationships that might lead to bias or a conflict of interest. No funding was received for this study, (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Non-operative management is common for low-impact pelvic fractures. In this study, we characterize the epidemiology of those treated nonoperatively following low-energy pelvic fracture, while identifying recent management trends., Methodology: Data from the Nationwide Inpatient Sample (NIS) database from 2011 to 2018 were analyzed. We identified adult patients diagnosed with pelvic fracture based on International Classification of Diseases (ICD) codes, excluding fractures of the acetabulum, femur, polytrauma, and open fractures to isolate cases caused by low-impact mechanisms. Codes indicating operative management were excluded. Demographic information and outcomes (length of stay, in-hospital mortality, hospital discharge status) were collected. Sub-analyses were performed to identify trends., Findings: 123,936 eligible patients were identified. The average age was 68.7 years. 70% were female, showing a decline from 75% to 66% over the study period. Pubic bone involvement was observed in 59% of fractures. The mean Charlson Comorbidity Index (CCI) was 3.83, corresponding to a 10-year survival rate of 58.5%, which remained relatively stable throughout the study period. 62.4% of patients received treatment at urban teaching hospitals. Average length of hospital stay was 6.3 days. Discharge to a skilled nursing facility (SNF) was the most common outcome, ranging from 62.1% to 65.0% during the study period, while 20.0% of patients were discharged home (18.4%-21.1%). Mean in-hospital mortality was 3.28%, showing no significant change, with higher rates among male patients (5.1%) and patients of Asian descent (3.8%)., Conclusion: The majority of patients receiving nonoperative treatment for low-energy pelvic fractures were females in their mid-60s with moderate comorbidity. The study reveals a relatively high in-hospital mortality rate of 3.28%, particularly among male patients and those of Asian descent, indicating the need for increased surveillance for further injury in these groups. Most patients were discharged to a SNF, highlighting the necessity for extended rehabilitation in this population. This persistent trend is noteworthy considering the growing emphasis on the cost of inpatient admissions and advancements in outpatient management of orthopedic injuries., Competing Interests: AF, SS, JA, NS: Declarations of interest: none. MW: Osteocentric, receives royalties for implant design, unrelated to this manuscript. AVK: Orthopedic Trauma Association, leadership role; Customsurg AG, stock/stock options holder., (© 2023 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Introduction: The Emergency Cardiology Coordinator (ECC) was a senior nursing role implemented from 14 April 2020 to 15 September 2020 at the Gold Coast Hospital and Health Service in South-East Queensland, Australia to streamline and expedite assessment of patients presenting to the Emergency Department (ED) with suspected cardiac problems. ECC implementation occurred in the context of the emergence of COVID-19. Evaluation of the impact of the ECC role focussed primarily on the time interval from triage to cardiology consult (TTCC)., Methods: ED and Cardiology Department data were extracted from electronic medical records for the period 2 September 2019 to 1 March 2021. The TTCC for each presenting problem (chest pain, palpitations, shortness of breath, altered level of consciousness) was compared between patients seen by the ECC and those not seen on the days the ECC worked. The effect of COVID-19 on TTCC was assessed by an interrupted time series analysis. Data recorded by the ECC included patients seen and interventions provided., Results: The ECC saw 378 patients. Most presented with chest pain (269/378, 71.2%). The ECC determined that 68.8% (260/378) required a cardiac assessment. Following COVID-19 the median weekly TTCC increased by 0.029 hours (1.74 min) each week on average relative to that beforehand (p=0.008). For patients seen by the ECC the median TTCC was 2.07 hours (interquartile range [IQR]: 1.44, 3.16) compared to 2.58 hours (IQR: 1.73, 3.80; p=0.007) for patients not seen by the ECC. Chest pain (ECC: 1.94 hours; no ECC: 2.41 hours; p=0.06) and non-obvious cardiac presenting problems (ECC: 1.77 hours; no ECC 3.05 hours; p=0.004) displayed the largest reductions in TTCC when the ECC was involved. Presentations with palpitations, respiratory distress and altered level of consciousness had similar TTCCs., Conclusion: The ECC role resulted in an overall decrease in TTCC despite the role coinciding with the emergence of COVID-19. In order to clarify the optimal strategy for the ECC role, further analyses involving patient risk factors and presenting problems along with a health economic evaluation of this model of care and the effect on patient outcomes will be required., (Copyright © 2023 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: The incidence of periprosthetic femur fracture (PPFF) in the setting of total hip arthroplasty (THA) is steadily increasing. We seek to address whether there is a difference in outcomes between Vancouver B fracture types managed with ORIF when the original stem was a press-fit stem versus a cemented stem., Methods: In this retrospective cohort study at a level 1 trauma center, we identified 136 patients over 65 years-of-age with Vancouver B-type fractures sustained between 2005 and 2019. Patients were treated by ORIF and had either cemented or press-fit stems prior to their injury. Outcomes were subsidence of the femoral implant, time to full weight bearing, rate of the hip implant revision, estimated blood loss (EBL), postoperative complications, and the one-year mortality rate., Results: A total of 103 (75.7%) press-fit and 33 (24.3%) cemented patients were reviewed. Patient baseline characteristics, Vancouver fracture sub-types, and implant characteristics were not found to be significantly different between groups. The difference in subsidence rates, postoperative complications, and time to weight bearing were not significantly different between groups. EBL and one-year mortality rate were significantly higher in the cemented group., Conclusions: In geriatric patients with Vancouver B type periprosthetic fractures managed with ORIF, patients with an originally press fit stem may have lower mortality, lower estimated blood loss, and similar subsidence and hospital length of stays when compared to those with a cemented stem., (© 2023. The Author(s).)

Incidence of pelvic and acetabular fracture is increasing in Europe. From 2007 to 2014 in the USA, this study found an age-adjusted incidence of 198 and 40 fractures/100,000/year, respectively, much higher than what has been described before. Incidence remained steady over that period and only a small increase in incidence of pelvic fracture in men was identified., Purpose: To determine the incidence of pelvic ring and acetabular fractures in the USA over the period 2007-2014 and to examine trends over time., Methods: Retrospective population-based observational study using data from the Nationwide Emergency Department Sample (NEDS), a 20% stratified all-payer sample of US hospital-based emergency departments (EDs). All patients seen in the ED and diagnosed with pelvic/acetabular fracture from 2007 to 2014 were included. The primary outcome was age-adjusted incidence of pelvic and acetabular fractures per 100,000 persons/years. Secondary outcomes included incidence stratified by age and sex, patient- and hospital-related characteristics, and ED procedures. Tests for linear trends were used to determine if there were statistically significant differences by sex and age groups over time., Results: The age-adjusted incidence of pelvic fracture was 198 fractures/100,000/year, 323 in women and 114 in men. The age-adjusted incidence of acetabular fracture was 40 fractures/100,000/year, 36 in women and 51 in men. A small increase in the age-adjusted incidence of pelvic fracture in men was the only significant trend observed during the study time (p = 0.03). Over that period, the mean age of patients at presentation increased, as well as their number of comorbidities and associated fragility fractures, and they were more often sent home or to nursing facilities., Conclusions: When considering all patients coming to the ED, not only those admitted to the hospital, adjusted incidence of pelvic and acetabular fracture is much higher than what has been described before. Contrarily to the global increase seen in other countries, incidence of pelvic and acetabular fractures dropped in the USA from 2007 to 2014 and only a small increase in age-adjusted incidence of pelvic fracture in men was identified., (© 2022. International Osteoporosis Foundation and Bone Health and Osteoporosis Foundation.)

Background: Insurance status is important as medical expenses may decrease the likelihood of follow-up after musculoskeletal trauma, especially for low-income populations. However, it is unknown what insurance factors are associated with follow-up care. In this study, we assessed the association between insurance plan benefits, the end of the post-surgical global period, and follow-up after musculoskeletal injury., Methods: This is a retrospective cohort study of 394 patients with isolated extremity fractures who were treated at three level-I trauma centers over four months in 2018. Paired t-tests were utilized to assess the likelihood of follow-up in relation to the 90-day post-surgical global period. Regression analysis was used to assess factors associated with the likelihood of follow-up. Supervised machine learning algorithms were used to develop predictive models of follow-up after the post-surgical global period., Results: Our final analysis included 328 patients. Likelihood of follow-up did not significantly change while within the post-surgical global period. When comparing follow-up within and outside of the post-surgical global period, there was a 20.1% decrease in follow-up between the 6-weeks and 6-month time points (68.3% versus 48.2%, respectively; p < 0.0001). Medicaid insurance compared to Medicare (OR 0.27, 95% confidence interval (CI) = [0.09, 0.84], p = 0.02) was a predictor of decreased likelihood of follow-up at 6-months post-operatively., Conclusions: Our study demonstrates a statistically significant decrease in follow-up for orthopaedic trauma patients after the post-surgical global period, particularly for patients with Medicaid or Private insurance., (© 2023. The Author(s).)

Purpose: Complete articular tibial plateau fractures are typically high-energy injuries associated with significant soft tissue trauma. The primary aim of this study was to evaluate the incidence of wound complications and need for soft tissue coverage after open, complete articular tibial plateau fractures. The secondary aim was to study the effect of timing of fixation and timing of flap coverage on deep infection rates in these injuries., Methods: This was a retrospective cohort study of consecutive patients > 18 years undergoing ORIF of a Bicondylar Tibial Plateau (BTP) fracture between 2001 and 2018. Surgical data were recorded for open fractures including number of debridements, timing of definitive ORIF and soft tissue coverage relative to injury. Primary outcomes included rates of deep infection and unplanned reoperation., Results: 508 AO/OTA 41C BTP fractures were identified, with 51 open fractures included in 50 patients with a mean (SD) age 45.7 (12.3) years and a mean (SD) follow up of 4.3 (3.8) years. There were 20 cases of deep infection, unplanned reoperation occurred in 26 cases. The majority of cases (28 fractures) had initial external fixation placed, while 24 had ORIF at the initial debridement. Twelve patients had a planned flap for definitive closure on average of 6.4 days (SD 3.9) after injury, 14 required a flap for wound complications. Among patients with IIB and C injuries, rates of deep infection (5/6 vs 1/6, p = 0.02) and reoperation (5/7 vs 2/6, p = 0.08) were higher in patients treated with flap coverage >7 days from injury compared to early flap coverage. There were no differences in complication rates between early (<24hrs) and delayed fixation., Conclusions: Complete articular, open tibial plateau fractures are associated with high rates of complications. Time to flap coverage of seven days or more was a significant predictor of deep infection and unplanned reoperation in this cohort. Patients should be counseled about the high rate of unplanned reoperation and definitive soft tissue coverage should be accomplished within a week of injury whenever possible., Competing Interests: Declaration of Competing Interest Dr. Von Keudell serves as a consultant for Stryker and Chief Medical Officer for CustomSurg AG, but does not have any conflicts of interest related to the material in this manuscript. Dr. Weaver receives royalties from OsteoCentric Technologies but does not have any conflicts of interest related to the material in this manuscript. Dr. Singh is owner and director of Universal Medical Supplies but does not have any conflicts of interest related to the material in this manuscript. The remaining authors do not have any disclosures or conflicts of interest to report., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Objective: To compare the adverse event profile and patient comorbidity profile of lower extremity orthopaedic trauma patients admitted via interfacility transfer (IT) to direct admission (DA) patients from home., Methods: A total of 39,497 patients from 2012 to 2019 were identified in the American College of Surgeon National Surgical Quality Improvement Program database. DA patients were compared with IT patients for differences in preoperative comorbidities, adverse events, length of stay, and readmissions in the 30-day postoperative period. Student t tests were used to assess continuous variables. Pearson χ 2 test and odds ratios (ORs) were used for categorical variables., Results: The IT group comprised 7167 patients, and the DA group comprised 32,330 patients. IT patients were on average older (65.5 vs. 58.8 years, P < 0.01), more likely to be American Society of Anesthesiologists Status >2 ( P < 0.01), and had a worse comorbidity profile for numerous preoperative risk factors. IT patients had significantly higher rates of mortality [3.3% vs. 1.4%; odds ratio (OR) 2.29; 95% confidence interval (CI), 1.96-2.77], major complications (10.2% vs. 6.1%; OR 1.74; 95% CI, 1.60-1.91), significantly higher readmission rates (5.8% vs. 4.8%, P < 0.01, OR 1.22 95% CI, 1.09-1.36), and more infectious complications (7% vs. 4.7%; OR 1.54; 95% CI, 1.38-1.71) than DA patients. Transfer remained a significant factor predicting major adverse events in regression analysis controlling for patient characteristics and fracture type ( P < 0.01; B 1.197; 95% CI, 1.09-1.32)., Conclusions: This study revealed that IT patients undergoing operative management of pelvic, acetabular, and lower extremity fractures are at a significantly increased risk of major complications, readmission, and have a higher morbidity burden than DA patients. As healthcare transitions to value-based care and bundled payments, hospitals that accept a high volume of ITs will face exposure to added risk and financial penalties without adequate policy protections., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: This is a retrospective study evaluating the use of a new six-item modified frailty index (MF-6) to predict short-term outcomes of patients receiving surgery for lower extremity fractures., Methods: Patients older than 65 years undergoing open reduction and internal fixation for lower extremity, pelvic, and acetabulum fractures were identified from the American College of Surgeons National Surgical Quality Improvement Program. The MF-6 was calculated by assigning one point for each of six common conditions. Multivariable analysis was used to compare patients with an MF-6 of <3 and ≥3. Outcome measures included complications, mortality, readmission, revision surgery, and length of stay. An area under the curve receiver operator analysis was conducted to compare the MF-6 with MF-5, an existing five-item frailty index., Results: Nine thousand four hundred sixty-three patients were included. Patients with an MF-6 of ≥3 were at markedly higher risk of discharge destination other than home (Exp[B] = 2.09), mortality (Exp[B] = 2.48), major adverse events (Exp[B] = 2.16), and readmission (Exp[B] = 1.82). Receiver-operating curve analysis demonstrated an area under the curve of 0.65 for mortality, 0.62 for major adverse events, and 0.62 for discharge destination other than home, all of which outperformed the MF-5., Discussion: The MF-6 was correlated with a 30-day postoperative incidence of infectious complications, readmission, and discharge destination. MF-6 scores can be used to risk-stratify patient populations as shifts to value-based care continue to develop., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Aims & Objectives: Our study sought to determine if posterior wall (PW) involvement in associated both-column acetabular fractures (ABCAFs) is associated with different clinical outcomes, primarily rate of conversion to total hip arthroplasty (THA), in comparison to ABCAFs with no PW involvement., Materials & Methods: This retrospective observational cohort study was performed at two academic Level 1 trauma centers. Two study groups were identified. The first study group consisted of 18 patients who sustained an ABCAF with PW involvement (+PW). The second study group consisted of 26 patients who sustained an ABCAF with no PW involvement (-PW). All patients achieved a minimum 12-months of follow-up and/or received a THA conversion procedure at a time remote to their index open reduction internal fixation (ORIF) procedure. The primary outcome of this study was subsequent conversion to THA on the injured hip. The secondary outcome was the presence of post-operative pain at ≥6 months and/or complications., Results: No difference in rate of conversion to THA between + PW (n = 4, 22.2%) and -PW (n = 3, 11.5%) groups was demonstrated (p = 0.419). Similarly, no differences were seen between groups regarding complication rate (p = 0.814) and post-operative pain (p = 0.142)., Conclusion: Involvement of the PW does not appear to create worse clinical outcomes in comparison to no involvement in ABCAFs particularly as it relates to ipsilateral joint replacement., Competing Interests: None., (© 2023 Professor P K Surendran Memorial Education Foundation. Published by Elsevier B.V. All rights reserved.)

Objective: To assess the impact of severe obesity on 30-day adverse event rates, hospital length of stay (LOS), readmissions, and projected costs after operative fixation of tibia and femur fractures., Methods: An analysis of the American College of Surgeons National Surgical Quality Improvement Project database from 2012 to 2019 of isolated femoral shaft and tibial shaft fracture fixation cases was conducted. Adverse events, LOS, readmission rates, and operative time were queried for severe obesity, defined as body mass index greater than 40, compared with other patients. Student t tests were used to assess continuous variables. Fisher exact test and odds ratios were used for categorical variables. A cost-analysis was also performed to quantify the effect of severe obesity on projected health care expenditures., Results: A total of 10,436 patients were included with 7.0% of patients categorized as severely obese. Severely obese patients had higher infectious complication rates (9.0% vs. 6.7%, P = 0.013, OR 1.36, 95% CI 1.04-1.78), readmission rates (7.9% vs. 5.6%, P-value = 0.008, OR 1.44, 95% CI 1.08-1.91), longer LOS (5.8 days SD ±10.2 vs. 5.0 days SD ±7.9 days, P-value = 0.008), and longer operative times (mean 115 minutes ± 56 minutes SD vs. 103 minutes SD ±54 minutes, P-value = <0.001). Severe obesity resulted in an estimated $4258.07 additional health care expenditures per patient compared with nonobese patients. This amounted to a projected added total expenditure of $3.09 million USD in the overall cohort., Conclusion: Severe obesity is associated with significantly worse 30-day outcomes and higher readmission rates for patients undergoing operative fixation of tibial shaft and femoral shaft fractures. Health policy considerations should be made to incentivize care for this patient population, particularly in trauma where modification of risk factors before surgery is often not feasible., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The use of reverse shoulder arthroplasty (RSA) to treat displaced, unstable 3- and 4-part proximal humerus fractures (PHFs) has traditionally been reserved for patients over 70 years old. However, recent data suggest that nearly one-third of all patients treated with RSA for PHF are between 55-69 years old. The purpose of this study was to compare outcomes for patients younger than 70 versus patients older than 70 years of age treated with RSA for a PHF or fracture sequelae., Methods: All patients who underwent primary RSA for acute PHF or fracture sequelae (nonunion, malunion) between 2004 and 2016 were identified. A retrospective cohort study was performed comparing outcomes for patients younger than 70 versus older than 70. Bivariate and survival analyses were performed to evaluate for survival complications, functional outcomes, and implant survival differences., Results: A total of 115 patients were identified, including 39 patients in the young group and 76 cases in the older group. In addition, 40 patients (43.5%) returned functional outcomes surveys at an average of 5.51 years (average age range: 3.04-11.0 years). There were no significant differences in complications, reoperation, implant survival, range of motion, DASH (27.9 vs 23.8, P=0.46), PROMIS (43.3 vs 43.6, P=0.93), or EQ5D (0.75 vs 0.80, P=0.36) scores between the two age cohorts., Conclusion: At a minimum of 3 years after RSA for a complex PHF or fracture sequelae, we found no significant difference in complications, reoperation rates, or functional outcomes between younger patients with an average age of 64 years and older patients with an average age of 78 years. To our knowledge, this is the first study to specifically examine the impact of age on outcome after RSA for the treatment of a proximal humerus fracture. These findings indicate that functional outcomes are acceptable to patients younger than 70 in the short term, but more studies are needed. Patients should be counseled that the long-term durability of RSA performed for fractures in young, active patients remains unknown.

Purpose: Prompt identification of traumatic pelvic fractures in the elderly is critical to guide clinical management; however, the accuracy of pelvic radiographs is often compromised by multiple factors. The purpose of this study is to examine the diagnostic accuracy of radiographs for the detection of pelvic fractures, with CT as the standard of reference., Methods: A retrospective review was performed of patients ≥ 65 years with traumatic pelvic fractures evaluated with both pelvic radiography and computed tomography (CT) from May 2016 to October 2019. Pelvic fractures were classified into fractures of the pubis, ilium, ischium, sacrum, and acetabulum. All pelvic radiographs were independently reviewed by two emergency radiologists. Original CT reports were utilized for the reference standard., Results: 177 patients were included, with a total of 555 fractures. The mean age was 81 years and 68% were female. The most common mechanism of injury was fall (62%), followed by motor vehicle accidents (18%). The most fractured bone was the pubis (314/555 fractures). Global pooled sensitivity for pelvic radiographs in detecting pelvic fractures compared to CT was 48%, with a specificity of 93%. Sensitivity for the detection of pelvic fractures is classified by the following types: pubis 61%, acetabulum 60%, ilium 41%, sacrum 20%, and ischium 17%. Eighteen patients (10%) required surgical fixation. Mortality was 8%., Conclusion: Pelvic radiographs have low sensitivity in detecting traumatic pelvic fractures. These radiographically occult fractures may be clinically significant as a cause of long-term pain and may require orthopedic consultation and possible surgical management., (© 2022. The Author(s), under exclusive licence to American Society of Emergency Radiology (ASER).)

Background: Tibial plateau fractures with an ipsilateral compartment syndrome are a clinical challenge with limited guidance regarding the best time to perform open reduction and internal fixation (ORIF) relative to fasciotomy wound closure. This study aimed to determine if the risk of fracture-related infection (FRI) differs based on the timing of tibial plateau ORIF relative to closure of ipsilateral fasciotomy wounds., Methods: A retrospective cohort study identified patients with tibial plateau fractures and an ipsilateral compartment syndrome treated with 4-compartment fasciotomy at 22 US trauma centers from 2009 to 2019. The primary outcome measure was FRI requiring operative debridement after ORIF. The ORIF timing relative to fasciotomy closure was categorized as ORIF before, at the same time as, or after fasciotomy closure. Bayesian hierarchical regression models with a neutral prior were used to determine the association between timing of ORIF and infection. The posterior probability of treatment benefit for ORIF was also determined for the three timings of ORIF relative to fasciotomy closure., Results: Of the 729 patients who underwent ORIF of their tibial plateau fracture, 143 (19.6%) subsequently developed a FRI requiring operative treatment. Patients sustaining infections were: 21.0% of those with ORIF before (43 of 205), 15.9% at the same time as (37 of 232), and 21.6% after fasciotomy wound closure (63 of 292). ORIF at the same time as fasciotomy closure demonstrated a 91% probability of being superior to before closure (RR, 0.75; 95% CrI, 0.38 to 1.10). ORIF after fasciotomy closure had a lower likelihood (45%) of a superior outcome than before closure (RR, 1.02; 95% CrI; 0.64 to 1.39)., Conclusion: Data from this multicenter cohort confirms previous reports of a high FRI risk in patients with a tibial plateau fracture and ipsilateral compartment syndrome. Our results suggest that ORIF at the time of fasciotomy closure has the highest probability of treatment benefit, but that infection was common with all three timings of ORIF in this difficult clinical situation., Competing Interests: Declaration of Competing Interests None., (Copyright © 2022. Published by Elsevier Ltd.)

Background: At the initiation of the COVID-19 pandemic, restrictions forced researchers to decide whether to continue their ongoing clinical trials. The PREPARE (Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities) trial is a pragmatic cluster-randomized crossover trial in patients with open and closed fractures. PREPARE was enrolling over 200 participants per month at the initiation of the pandemic. We aim to describe how the COVID-19 research restrictions affected participant enrollment., Methods: The PREPARE protocol permitted telephone consent, however, sites were obtaining consent in-person. To continue enrollment after the initiation of the restrictions participating sites obtained ethics approval for telephone consent scripts and the waiver of a signature on the consent form. We recorded the number of sites that switched to telephone consent, paused enrollment, and the length of the pause. We used t-tests to compare the differences in monthly enrollment between July 2019 and November 2020., Results: All 19 sites quickly implement telephone consent. Fourteen out of nineteen (73.6%) sites paused enrollment due to COVID-19 restrictions. The median length of enrollment pause was 46.5 days (range, 7-121 days; interquartile range, 61 days). The months immediately following the implementation of restrictions had significantly lower enrollment., Conclusion: A pragmatic design allowed sites to quickly adapt their procedures for obtaining informed consent via telephone and allowed for minimal interruptions to enrollment during the pandemic., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 Published by Elsevier Inc.)

Advanced posttraumatic osteoarthritis (PTOA) of the knee is a cause of substantial disability, particularly in younger individuals, and the treatment of choice is total knee arthroplasty (TKA). Racial and socioeconomic disparities exist in the use of TKA, but, to our knowledge, there have been no studies examining these disparities among patients with PTOA., Methods: We performed chi-square and logistic regression analyses on data from the Nationwide Inpatient Sample (NIS). The outcome of interest was the rate of TKA utilization, and the primary predictors were racial/ethnic group and insurance status. The regression models were adjusted for age, sex, household income, and Charlson Comorbidity Index (CCI)., Results: The odds of receiving TKA for Black patients (odds ratio [OR] = 0.55; 95% confidence interval [CI], 0.48 to 0.62) and Hispanic patients (OR = 0.53; 95% CI, 0.46 to 0.62) were lower compared with White patients. Patients with Medicare (OR = 0.51; 95% CI, 0.46 to 0.57), those with Medicaid (OR = 0.48; 95% CI, 0.42 to 0.55), and those who self-paid (OR = 0.91, 95% CI: 0.14 to 0.25) had significantly lower odds of TKA compared with those with private insurance., Conclusions: Black and Hispanic patients are less likely than White patients to utilize TKA, and patients with private insurance are more likely to utilize TKA., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A412)., (Copyright © 2022 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

From the orthopedic trauma surgeon's perspective, successful injury management hinges on fracture fixation and restoration of patient mobility in a safe and expeditious manner. Management of critically injured polytrauma patients and shared decisions regarding regional anesthetics presents a myriad of challenges for orthopedic trauma surgeons and anesthesiologists alike. As the populations age, the typical patient sustaining traumatic orthopedic injuries are increasingly frail and elderly. This trend in demographics has mandated that care for orthogeriatric patients is coordinated by multidisciplinary teams working in concert on medically complex cases to a common end. In this article, we highlight opportunities for improved communication and care integration between orthopedic trauma surgeons and anesthesiologists., Competing Interests: Disclosure None of the authors declared financial, consultant, institutional, or other disclosures related to the research in this article., (Copyright © 2022 Elsevier Inc. All rights reserved.)

A series of 10-alkoxy-Anthryl-isoxazole-pyrrole-doubletails (RO-AIMs) were synthesized using a crown ether assisted nucleophilic aromatic substitution followed by a modified Schotten-Baumann reaction. The novel RO-AIMs described here exhibit robust growth inhibition for the human SNB19 CNS glioblastoma cell line, and biphenyl analog 8c had activity in the nanomolar regime, which represents the most efficacious compound in the AIM series to date. Computational modeling for RO-AIMs binding in a ternary complex with c-myc quadruplex DNA and its helicase DHX36 is presented which represents our current working hypothesis., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

The COVID-19 pandemic had wide-reaching effects on healthcare delivery, including care for hip fractures, a common injury among older adults. This study characterized factors related to surgical timing and outcomes, length-of-stay, and discharge disposition among patients treated for operative hip fractures during the first wave of the COVID-19 pandemic, compared to historical controls. A retrospective, observational cohort study was conducted from 16 March-20 May 2020 with a consecutive series of 64 operative fragility hip fracture patients at three tertiary academic medical centers. Historical controls were matched based on sex, surgical procedure, age, and comorbidities. Primary outcomes included 30-day mortality and time-to-surgery. Secondary outcomes included 30-day postoperative complications, length-of-stay, discharge disposition, and time to obtain a COVID-19 test result. There was no difference in 30-day mortality, complication rates, length-of-stay, anesthesia type, or time-to-surgery, despite a mean time to obtain a final preoperative COVID-19 test result of 17.6 h in the study group. Notably, 23.8% of patients were discharged to home during the COVID-19 pandemic, compared to 4.8% among controls ( p = 0.003). On average, patients received surgical care within 48 h of arrival during the COVID-19 pandemic. More patients were discharged to home rather than a facility with no change in complications, suggesting an opportunity for increased discharge to home.

Objectives: To compare the risk of deep infection and unplanned reoperation after staged open reduction internal fixation (ORIF) of bicondylar tibial plateau (BTP) fractures whether elements of the temporizing external fixator were prepped into the surgical field or completely removed before definitive fixation., Design: Retrospective comparative cohort study., Setting: Two academic Level 1 trauma centers., Patients/participants: One hundred forty-seven OTA/AO 41-C (Schatzker 6) BTP fractures treated with a 2-stage protocol of acute spanning ex-fix followed by definitive ORIF between 2001 and 2018., Intervention: Seventy-eight fractures had retained elements of the original ex-fix prepped in situ during surgery for definitive internal fixation, and 69 had the ex-fix construct completely removed before prepping and draping., Main Outcome Measures: Deep infection and unplanned reoperation., Results: Among 147 patients treated with staged ORIF, the overall deep infection rate was 26.5% and the reoperation rate was 33.3%. There were high rates of deep infection (26.9% vs. 26.1%, P = 0.909) and unplanned reoperation (30.8% vs. 36.2%, P = 0.483) in both groups, but no difference whether the ex-fix was prepped in or completely removed. Within the retained ex-fix group, there was no difference in infection with retention of the entire ex-fix compared with only the ex-fix pins (28.1% vs. 26.1%, P = 0.842)., Conclusions: We observed high complication rates in this cohort of OTA/AO 41C BTP fractures treated with staged ORIF, but prepping in the ex-fix did not lead to a significant increase in rates of infection or reoperation. This study provides the treating surgeon with clinical data about a common practice used to facilitate definitive fixation of unstable BTP fractures., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: M.B. Harris is an unpaid consultant for OsteoCentric Technologies, M.J. Weaver reports royalties from OsteoCentric Technologies not related to the subject of this article, and A.G. Von Keudell reports consulting fees from Stryker not related to the subject of this article. The remaining authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To assess prevalence of CT imaging-derived sarcopenia, osteoporosis, and visceral obesity in clinically frail and prefrail patients and determine their association with the diagnosis of frailty., Materials and Methods: This cross-sectional study was constructed using our institution's pelvic trauma registry and ambulatory database registry. The study included all elderly pelvic trauma patients and ambulatory outpatients between May 2016 and March 2020 who had a comprehensive geriatric assessment and CT abdomen/pelvis within 1 year from the date of the assessment. Patients were dichotomized in prefrail or frail groups. The study excluded patients with history of metastatic disease or malignancy requiring chemotherapy., Results: The study cohort consisted of 151 elderly female and 65 male patients. Each gender population was subdivided into frail (114 female [75%], 51 male [78%]) and prefrail (37 female [25%], 14 male [22%]) patients. CT-imaging-derived diagnosis of osteoporosis (odds ratio, 2.5; 95% CI: 1.2-5.5) and sarcopenia (odds ratio, 2.6; 95% CI: 1.2-5.6) were associated with frailty in females, but did not reach statistical significance in males. BMI and subcutaneous adipose tissue at L3 level were statistically lower in the frail male group compared to the prefrail group. BMI showed strong correlation with the subcutaneous area at the L3 level in both genders (Spearman's coefficient of 0.8, p < 0.001). Hypoalbuminemia and visceral obesity were not associated with frailty in either gender., Conclusion: This proof-of-concept study demonstrates the feasibility of using CT-derived body-composition parameters as a screening tool for frailty, which can offer an opportunity for early medical intervention., (© 2021. ISS.)

The syntheses and structures of an unexpected by-product from an iodination reaction, namely, ethyl 5-methyl-3-(10-nitro-anthracen-9-yl)isoxazole-4-carb-oxy-l-ate, C 21 H 16 N 2 O 5 , (I), and its oxidation product, ethyl 3-(9-hy-droxy-10-oxo-9,10-di-hydro-anthracen-9-yl)-5-methyl-isoxazole-4-carboxyl-ate, C 21 H 17 NO 5 (V) are described. Compound (I) crystallizes with two mol-ecules in the asymmetric unit in which the dihedral angles between the anthracene fused-ring systems and isoxazole ring mean planes are 88.67 (16) and 85.64 (16)°; both mol-ecules feature a disordered nitro group. In (V), which crystallizes with one mol-ecule in the asymmetric unit, the equivalent dihedral angle between the almost planar anthrone ring system (r.m.s. deviation = 0.029 Å) and the pendant isoxazole ring is 89.65 (5)°. In the crystal of (I), the mol-ecules are linked by weak C-H⋯O inter-actions into a three-dimensional network and in the extended structure of (V), inversion dimers linked by pairwise O-H⋯O hydrogen bonds generate R 2 2 (14) loops., (© Li et al. 2022.)

Background: The surgical management of bicondylar tibial plateau (BTP) fractures in elderly patients aims to restore knee stability while minimizing soft tissue complications. The purpose of this study was to compare injury characteristics and surgical outcomes after ORIF of BTP fractures (AO/OTA 41-C (Schatzker VI)) in young (< 50 years) versus elderly (> 65 years) patients., Methods: A retrospective cohort study was conducted using data from two American College of Surgeons (ACS) level I trauma centers. Inclusion criteria were: (1) age 18 years or older, (2) bicondylar tibial plateau fracture (AO/OTA 41-C or Schatzker VI), (3) treatment with ORIF, and (4) minimum of 6 months follow-up. Patients between 50 and 65 years of age were excluded. Data collection was performed by reviewing electronic medical records, operative reports, and radiology reports., Results: We identified 323 patients (61% male) with 327 BTP fractures and a median follow-up of 685 days. There were 230 young patients (71%) < 50 years and 93 elderly patients (29%) >6 5 years at time of presentation. Elderly patients were significantly more likely to have a low energy mechanism of injury (44.6 vs. 16.2%, p < 0.001), and present with diabetes (19.4 vs. 4.4%, p < 0.001) or coronary artery disease (12.9 vs. 1.3%, p < 0.001). Elderly patients were also significantly less likely to undergo staged management with initial knee-spanning external fixation followed by delayed ORIF (19.2 vs. 33.9%, p = 0.008). Elderly patients had a lower arc of motion at final follow-up (105 vs. 113°, p < 0.001) and reduced PROMIS-10 function scores (43.8 vs. 49.8, p = 0.013). No differences were observed in rates of superficial infection, deep infection, reoperation, or EQ-5D scores between age groups., Conclusions: This is the largest study to compare injury characteristics and outcomes after ORIF of BTP fractures according to age. Elderly patients (age > 65 years) sustained BTP fractures by lower energy mechanisms than their younger counterparts with similar fracture patterns and were often managed with ORIF. The results of this study suggest that ORIF of BTP fractures in elderly patients is associated with similar complication rates and outcomes as in younger patients despite higher comorbidities and poorer bone quality in the elderly population., (Copyright © 2022 Elsevier Ltd. All rights reserved.)