Evidence-based treatment of Achilles tendon rupture.

The treatment of Achilles tendon rupture has recently seen a shift toward non-operative management, as supported by the literature, yet many surgeons continue to treat these injuries operatively. The evidence clearly supports non-operative management of these injuries except for Achilles insertional tears and for certain patient groups, such as athletic patients, for whom further research is warranted. This nonadherence to evidence-based treatment may be explained by patient preference, surgeon subspecialty, surgeon era of practice or other variables. Further research to understand the reasons behind this nonadherence would help to promote conformity in the surgical community across all specialties and adherence to evidence-based approaches.

How Successful Is Antibiotic Treatment for Superficial Surgical Site Infections After Open Fracture? A Fluid Lavage of Open Wounds (FLOW) Cohort Secondary Analysis.

BACKGROUND: Although many studies report the incidence and prevalence of surgical site infections (SSIs) after open fractures, there is limited information on the treatment and subsequent outcomes of superficial SSIs in patients with open fractures. Additionally, clinical studies describing the factors that are associated with persistent infection after nonoperative treatment with antibiotics for patients with superficial SSIs are lacking. QUESTIONS/PURPOSES: Therefore, we asked: (1) What proportion of patients with superficial SSIs after open fracture treatment developed persistent infection after nonoperative treatment (that is, treatment with antibiotics alone)? (2) What risk factors are associated with SSIs that do not resolve with nonoperative (antibiotic) treatment? As a secondary objective, we planned to analyze the microbiological information about participants wound cultures, when these were available, and the proportion of positive cultures for patients whose SSIs were not resolved by antibiotics alone. METHODS: This is a secondary analysis of the Fluid Lavage of Open Wounds (FLOW) trial dataset. The FLOW trial included 2445 patients with operatively managed open fractures. FLOW participants who had a nonoperatively managed superficial SSI diagnosed in the 12 months post-fracture were included in this analysis. Superficial SSIs were diagnosed in 168 participants within 12 months of their fracture. Of these, 83% (139) had their superficial SSI treated with antibiotics alone. Participants were grouped into two categories: (1) 97 participants whose treatment with antibiotics alone resolved the superficial SSI and (2) 42 participants whose treatment with antibiotics alone did not resolve the SSI (defined as undergoing surgical management or the SSI being unresolved at latest follow-up [12-months post-fracture for the FLOW trial]). Of the participants whose treatment with antibiotics alone resolved the SSI, 92% (89 of 97) had complete follow-up, 6% (6 of 97) were lost to follow-up before 12 months, 1% (1 of 97) withdrew consent from the study before 12 months, and 1% (1 of 97) experienced mortality before 12 months. Of the participants whose treatment with antibiotics alone did not resolve the SSI, 90% (38 of 42) had complete follow-up, 7% (3 of 42) were lost to follow-up before 12 months, and 2% (1 of 42) withdrew consent from the study before 12 months. A logistic binary regression analysis was conducted to identify factors associated with persistent infection despite superficial SSI antibiotic treatment. Based on biologic rationale and previous evidence, we identified a priori 13 potential factors (corresponding to 14 levels) to be included in the regression model. RESULTS: The antibiotic treatment resolved the superficial SSI in 70% (97 of 139) of patients and did not resolve the SSI in 30% (42 of 139). After controlling for potential confounding variables, such as age, fracture severity, and time from injury to initial surgical irrigation and débridement, superficial SSIs diagnosed later in follow-up were associated with antibiotics not resolving the SSI (odds ratio 1.05 [95% CI 1.004 to 1.009] for every week of follow-up; p = 0.03). Sex, fracture pattern, and wound size were not associated with antibiotics not resolving the SSI. CONCLUSIONS: Our secondary analysis of prospectively collected FLOW data suggests that antibiotics alone can be an appropriate treatment option when treating superficial SSIs after an open fracture wound, especially when promptly diagnosed. Further research with longer follow-up time is needed to better identify the natural history of superficial SSIs and possibly some dormant or subclinical infections to help clinicians in the treatment decision-making process. LEVEL OF EVIDENCE: Level III, therapeutic study.

A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds.

BACKGROUND: The management of open fractures requires wound irrigation and débridement to remove contaminants, but the effectiveness of various pressures and solutions for irrigation remains controversial. We investigated the effects of castile soap versus normal saline irrigation delivered by means of high, low, or very low irrigation pressure. METHODS: In this study with a 2-by-3 factorial design, conducted at 41 clinical centers, we randomly assigned patients who had an open fracture of an extremity to undergo irrigation with one of three irrigation pressures (high pressure [>20 psi], low pressure [5 to 10 psi], or very low pressure [1 to 2 psi]) and one of two irrigation solutions (castile soap or normal saline). The primary end point was reoperation within 12 months after the index surgery for promotion of wound or bone healing or treatment of a wound infection. RESULTS: A total of 2551 patients underwent randomization, of whom 2447 were deemed eligible and included in the final analyses. Reoperation occurred in 109 of 826 patients (13.2%) in the high-pressure group, 103 of 809 (12.7%) in the low-pressure group, and 111 of 812 (13.7%) in the very-low-pressure group. Hazard ratios for the three pairwise comparisons were as follows: for low versus high pressure, 0.92 (95% confidence interval [CI], 0.70 to 1.20; P=0.53), for high versus very low pressure, 1.02 (95% CI, 0.78 to 1.33; P=0.89), and for low versus very low pressure, 0.93 (95% CI, 0.71 to 1.23; P=0.62). Reoperation occurred in 182 of 1229 patients (14.8%) in the soap group and in 141 of 1218 (11.6%) in the saline group (hazard ratio, 1.32, 95% CI, 1.06 to 1.66; P=0.01). CONCLUSIONS: The rates of reoperation were similar regardless of irrigation pressure, a finding that indicates that very low pressure is an acceptable, low-cost alternative for the irrigation of open fractures. The reoperation rate was higher in the soap group than in the saline group. (Funded by the Canadian Institutes of Health Research and others; FLOW ClinicalTrials.gov number, NCT00788398.).

Are large clinical trials in orthopaedic trauma justified?

BACKGROUND: The objective of this analysis is to evaluate the necessity of large clinical trials using FLOW trial data. METHODS: The FLOW pilot study and definitive trial were factorial trials evaluating the effect of different irrigation solutions and pressures on re-operation. To explore treatment effects over time, we analyzed data from the pilot and definitive trial in increments of 250 patients until the final sample size of 2447 patients was reached. At each increment we calculated the relative risk (RR) and associated 95% confidence interval (CI) for the treatment effect, and compared the results that would have been reported at the smaller enrolments with those seen in the final, adequately powered study. RESULTS: The pilot study analysis of 89 patients and initial incremental enrolments in the FLOW definitive trial favored low pressure compared to high pressure (RR: 1.50, 95% CI: 0.75-3.04; RR: 1.39, 95% CI: 0.60-3.23, respectively), which is in contradiction to the final enrolment, which found no difference between high and low pressure (RR: 1.04, 95% CI: 0.81-1.33). In the soap versus saline comparison, the FLOW pilot study suggested that re-operation rate was similar in both the soap and saline groups (RR: 0.98, 95% CI: 0.50-1.92), whereas the FLOW definitive trial found that the re-operation rate was higher in the soap treatment arm (RR: 1.28, 95% CI: 1.04-1.57). CONCLUSIONS: Our findings suggest that studies with smaller sample sizes would have led to erroneous conclusions in the management of open fracture wounds. TRIAL REGISTRATION: NCT01069315 (FLOW Pilot Study) Date of Registration: February 17, 2010, NCT00788398 (FLOW Definitive Trial) Date of Registration: November 10, 2008.

Orthopaedic Trainees Retain Knowledge After a Partner Abuse Course: An Education Study.

INTRODUCTION: Intimate partner violence (IPV) is a serious global issue that results in a large number of injuries and deaths among women. Educating clinicians about IPV can help providers identify, prevent, and treat victims, and, ultimately, improve care for victims of abuse. We sought to determine the effect of a half-day educational course on IPV for orthopaedic surgical trainees on knowledge and attitudes. QUESTIONS/PURPOSES: We asked (1) whether a half-day educational course on IPV can improve orthopaedic surgical trainees' knowledge and (2) attitudes regarding IPV; and (3) whether a course on IPV can be accepted and viewed as valuable by trainees? METHODS: Using published research on IPV in patients with musculoskeletal injuries, we developed a half-day educational course. The curriculum included lectures and discussion regarding the basics of IPV, the current state of IPV research, what to do when a patient is a victim or perpetrator, and the orthopaedic surgeon's role in recognizing, preventing, and assisting with IPV. All 33 course participants (30 men and three women), all orthopaedic surgical trainees, completed a questionnaire that included general true or false or agree or disagree statements regarding their knowledge, attitudes, and practices of IPV in the musculoskeletal setting; the questionnaire also included a knowledge test of 25 true or false statements. The questionnaire was administered immediately before, immediately after, and 3 months after the course; 76% (25 of 33) took the test immediately after the course and 82% (27 of 33) completed the test at 3 months. Participant knowledge scores were compared across the three different times to determine the effect of the course. RESULTS: Participants increased their knowledge after the course, and the increased knowledge was retained at retesting at 3 months; the mean percentage of correct answers before the course was 57%, which increased to 73% after the course, and was 68% 3 months later (F = 9.505; p = 0.001). Before the course, most of the course participants (30 of 32; 94%) agreed that IPV is an important issue; agreement increased to 100% immediately after the course. The largest change in attitude was in response to the statement: "I am skeptical that the health care system has the resources to screen for IPV." Before the course, 53% (17 of 32) of trainees endorsed this statement, but the percent decreased to 36% (nine of 25) after the course and remained low at 33% (nine of 27), at the 3-month test. CONCLUSIONS: Our findings show that a short course on IPV in patients with musculoskeletal injuries led to an improvement and retention of knowledge 3 months after the course. Based on our findings, we recommend that IPV education be integrated in training programs for orthopaedic surgeons. Future projects should focus on developing and implementing a sustainable education program that can affect practice for healthcare professionals and trainees in multiple clinical settings.

Network Meta-analysis: Users' Guide for Surgeons: Part I - Credibility.

Conventional meta-analyses quantify the relative effectiveness of two interventions based on direct (that is, head-to-head) evidence typically derived from randomized controlled trials (RCTs). For many medical conditions, however, multiple treatment options exist and not all have been compared directly. This issue limits the utility of traditional synthetic techniques such as meta-analyses, since these approaches can only pool and compare evidence across interventions that have been compared directly by source studies. Network meta-analyses (NMA) use direct and indirect comparisons to quantify the relative effectiveness of three or more treatment options. Interpreting the methodologic quality and results of NMAs may be challenging, as they use complex methods that may be unfamiliar to surgeons; yet for these surgeons to use these studies in their practices, they need to be able to determine whether they can trust the results of NMAs. The first judgment of trust requires an assessment of the credibility of the NMA methodology; the second judgment of trust requires a determination of certainty in effect sizes and directions. In this Users' Guide for Surgeons, Part I, we show the application of evaluation criteria for determining the credibility of a NMA through an example pertinent to clinical orthopaedics. In the subsequent article (Part II), we help readers evaluate the level of certainty NMAs can provide in terms of treatment effect sizes and directions.

Network Meta-analysis: Users' Guide for Surgeons: Part II - Certainty.

In the previous article (Network Meta-analysis: Users' Guide for Surgeons-Part I, Credibility), we presented an approach to evaluating the credibility or methodologic rigor of network meta-analyses (NMA), an innovative approach to simultaneously addressing the relative effectiveness of three or more treatment options for a given medical condition or disease state. In the second part of the Users' Guide for Surgeons, we discuss and demonstrate the application of criteria for determining the certainty in effect sizes and directions associated with a given treatment option through an example pertinent to clinical orthopaedics.

Emotional intelligence in orthopedic surgery residents.

BACKGROUND: Emotional intelligence (EI) is the ability to understand and manage emotions in oneself and others. It was originally popularized in the business literature as a key attribute for success that was distinct from cognitive intelligence. Increasing focus is being placed on EI in medicine to improve clinical and academic performance. Despite the proposed benefits, to our knowledge, there have been no previous studies on the role of EI in orthopedic surgery. We evaluated baseline data on EI in a cohort of orthopedic surgery residents. METHODS: We asked all orthopedic surgery residents at a single institution to complete an electronic version of the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT). We used completed questionnaires to calculate total EI scores and 4 branch scores. Data were analyzed according to a priori cutoff values to determine the proportion of residents who were considered competent on the test. Data were also analyzed for possible associations with age, sex, race and level of training. RESULTS: Thirty-nine residents (100%) completed the MSCEIT. The mean total EI score was 86 (maximum score 145). Only 4 (10%) respondents demonstrated competence in EI. Junior residents (p = 0.026), Caucasian residents (p = 0.009) and those younger than 30 years (p = 0.008) had significantly higher EI scores. CONCLUSION: Our findings suggest that orthopedic residents score low on EI based on the MSCEIT. Optimizing resident competency in noncognitive skills may be enhanced by dedicated EI education, training and testing.

CONTEXTE: L'intelligence émotionnelle (IÉ) est la capacité de comprendre et de gérer les émotions qui se manifestent en soi-même et chez les autres. À l'origine, le concept d'IÉ a été popularisé dans le monde des affaires en tant qu'attribut clé de la réussite, distinct de l'intelligence cognitive. On s'intéresse de plus en plus à l'IÉ pour améliorer l'acquisition des compétences cliniques et théoriques. Or, malgré les avantages évoqués, à notre connaissance, aucune étude n'a encore porté sur le rôle de l'IÉ en chirurgie orthopédique. Nous avons évalué les données de base concernant l'IÉ d'une cohorte de résidents en chirurgie orthopédique. MÉTHODES: Nous avons demandé à tous les résidents en chirurgie orthopédique d'un seul établissement de répondre à un questionnaire par voie électronique, soit le test d'intelligence émotionnelle de Mayer­Salovey­Caruso (MSCEIT). Nous avons utilisé les questionnaires dûment remplis pour calculer les scores d'IÉ totaux et 4 scores secondaires. Les données ont été analysées en fonction de valeurs-seuils préalablement établies afin de déterminer la proportion de résidents jugés compétents à l'aune de ce test. Les données ont aussi été analysées en fonction de liens possibles avec l'âge, le sexe, la race et le niveau de formation. RÉSULTATS: Trente-neuf résidents (100 %) ont répondu au test MSCEIT. Le score d'IÉ total moyen a été de 86 (score maximum 145). Seuls 4 répondants (10 %) ont démontré une compétence en matière d'IÉ. Les résidents juniors (p = 0,026), de race blanche (p = 0,009) et de moins de 30 ans (p = 0,008) ont présenté des scores d'IÉ significativement plus élevés. CONCLUSION: Selon nos conclusions, les résidents en orthopédie obtiennent des scores faibles pour ce qui est de l'IÉ selon le test MSCEIT. Il serait possible d'améliorer les compétences non cognitives des résidents au moyen de cours, de stages et de tests d'IÉ.

Time to full weight-bearing with the use of a calcium sulfate-calcium phosphate bone substitute as a bone void filler following extended curettage in the treatment of primary benign bone tumours.

PURPOSE: The primary objective of this study was to determine time to full weight-bearing after the use of a calcium-sulfate-calcium phosphate bone substitute (CaSO4/CaPO4) as a bone void filler in the treatment of primary benign bone tumours following intralesional curettage. The secondary objectives were to determine surgical complications and recurrence rates. METHODS: Retrospective review of patients identified from a surgeon-specific orthopaedic oncology database, who underwent curettage of benign bone tumours and subsequent bone void filling with CaSO4/CaPO4. RESULTS: A total of 39 patients (20 males, 19 females) met inclusion criteria with an average age of 31 years (range: 13 to 62 years), a median follow-up of 3.7 years, and a maximum follow-up of 11 years. The most common tumour diagnosis was giant cell tumour of bone (GCT) (n = 19), and the most common location was the proximal tibia (n = 9). The mean volume of tumour excised was 74.1 cm3 including extraosseous bone expansion due to tumour growth, with a mean of volume of 21.4 mL of CaSO4/CaPO4 used to fill the intraosseous cavitary defects to restore normal bone anatomy. None of the lesions required additional internal fixation. The primary outcome measure, average time to full weight-bearing/full range of motion, was 11 weeks and 6 weeks for upper and lower extremity lesions, respectively. Secondary outcomes included tumour recurrence requiring reoperation in five patients and infection requiring reoperation in two patients. CONCLUSION: This study demonstrates that CaSO4/CaPO4 is a viable option as a bone void filler in the reconstruction of cavitary defects following removal of primary benign bone tumours. CaSO4/CaPO4 provides sufficient bone regeneration early in the post-operative period to allow progression to full weight-bearing within weeks without the need for internal fixation. There were no graft-specific complications noted.

Barriers to and facilitators for screening women for intimate partner violence in surgical fracture clinics: a qualitative descriptive approach.

BACKGROUND: Intimate Partner Violence (IPV) is a major health issue that involves any physical, sexual or psychological harm inflicted by a current or former partner. Musculoskeletal injuries represent the second most prevalent clinical manifestation of IPV. Health care professionals, however, rarely screen women for IPV. Using qualitative methods, this study aimed to explore the perceived barriers to IPV screening and potential facilitators for overcoming these barriers among orthopaedic surgeons and surgical trainees. METHODS: We conducted three focus groups with orthopaedic surgeons, senior surgical trainees, and junior surgical trainees. A semi-structured focus group guide was used to structure the discussions. Transcripts and field notes from the focus groups were analyzed using the qualitative software program N'Vivo (version 10.0; QSR International, Melbourne, Australia). To further inform our focus group findings and discuss policy changes, we conducted interviews with two opinion leaders in the field of orthopaedics. Similar to the focus groups, the interviews were digitally recorded and transcribed, and then analyzed. RESULTS: In the analysis, four categories of barriers were identified: surgeon perception barriers; perceived patient barriers; fracture clinic barriers and orthopaedic health care professional barriers. Some of the facilitators identified included availability of a crisis team; development of a screening form; presence of IPV posters or buttons in the fracture clinic; and the need for established policy or government support for IPV screening. The interviewees identified the need for: the introduction of evidence-based policy aiming to increase awareness about IPV among health care professionals working within the fracture clinic setting, fostering local and national champions for IPV screening, and the need to generate change on a local level. CONCLUSIONS: There are a number of perceived barriers to screening women in the fracture clinic for IPV, many of which can be addressed through increased education and training, and additional resources in the fracture clinic. Orthopaedic health care professionals are supportive of implementing an IPV screening program in the orthopaedic fracture clinic.

Radiographic union score for hip substantially improves agreement between surgeons and radiologists.

BACKGROUND: Despite the prominence of hip fractures in orthopedic trauma, the assessment of fracture healing using radiographs remains subjective. The variability in the assessment of fracture healing has important implications for both clinical research and patient care. With little existing literature regarding reliable consensus on hip fracture healing, this study was conducted to determine inter-rater reliability between orthopedic surgeons and radiologists on healing assessments using sequential radiographs in patients with hip fractures. Secondary objectives included evaluating a checklist designed to assess hip fracture healing and determining whether agreement improved when reviewers were aware of the timing of the x-rays in relation to the patients' surgery. METHODS: A panel of six reviewers (three orthopedic surgeons and three radiologists) independently assessed fracture healing using sequential radiographs from 100 patients with femoral neck fractures and 100 patients with intertrochanteric fractures. During their independent review they also completed a previously developed radiographic checklist (Radiographic Union Score for Hip (RUSH)). Inter and intra-rater reliability scores were calculated. Data from the current study was compared to the findings from a previously conducted study where the same reviewers, unaware of the timing of the x-rays, completed the RUSH score. RESULTS: The agreement between surgeons and radiologists for fracture healing was moderate for "general impression of fracture healing" in both femoral neck (ICC = 0.60, 95% CI: 0.42-0.71) and intertrochanteric fractures (0.50, 95% CI: 0.33-0.62). Using a standardized checklist (RUSH), agreement was almost perfect in both femoral neck (ICC = 0.85, 95% CI: 0.82-0.87) and intertrochanteric fractures (0.88, 95% CI: 0.86-0.90). We also found a high degree of correlation between healing and the total RUSH score using a Receiver Operating Characteristic (ROC) analysis, there was an area under the curve of 0.993 for femoral neck cases and 0.989 for intertrochanteric cases. Agreement within the radiologist group and within the surgeon group did not significantly differ in our analyses. In all cases, radiographs in which the time from surgery was known resulted in higher agreement scores compared to those from the previous study in which reviewers were unaware of the time the radiograph was obtained. CONCLUSIONS: Agreement in hip fracture radiographic healing may be improved with the use of a standardized checklist and appears highly influenced by the timing of the radiograph. These findings should be considered when evaluating patient outcomes and in clinical studies involving patients with hip fractures. Future research initiatives are required to further evaluate the RUSH checklist.

Predictors of nonunion and reoperation in patients with fractures of the tibia: an observational study.

BACKGROUND: Tibial shaft fractures are the most common long bone fracture and are prone to complications such as nonunion requiring reoperations to promote fracture healing. We aimed to determine the fracture characteristics associated with tibial fracture nonunion, and their predictive value on the need for reoperation. We further aimed to evaluate the predictive value of a previously-developed prognostic index of three fracture characteristics on nonunion and reoperation rate. METHODS: We conducted an observational study and developed a risk factor list from previous literature and key informants in the field of orthopaedic surgery, as well as via a sample-to-redundancy strategy. We evaluated 22 potential risk factors for the development of tibial fracture nonunion in 200 tibial fractures. We also evaluated the predictive value of a previously-identified prognostic risk index on secondary intervention and/or reoperation rate. Two individuals independently extracted the data from 200 patient electronic medical records. An independent reviewer assessed the initial x-ray, the post-operative x-ray, and all available sequential x-rays. Regression and chi-square analysis was used to evaluate potential associations. RESULTS: In our cohort of patients, 37 (18.5%) had a nonunion and 27 (13.5%) underwent a reoperation. Patients with a nonunion were 97 times (95% CI 25.8-366.5) more likely to have a reoperation. Multivariable logistic regression revealed that fractures with less than 25% cortical continuity were predictive of nonunion (odds ratio = 4.72; p = 0.02). Such fractures also accounted for all of the reoperations identified in our sample. Furthermore, our data provided preliminary validation of a previous risk index predictive of reoperation that includes the presence of a fracture gap post-fixation, open fracture, and transverse fracture type as variables, with an aggregate of fracture gap and an open fracture yielding patients with the highest risk of developing a nonunion. CONCLUSIONS: We identified a significant association between degree of cortical continuity and the development of a nonunion and risk for reoperation in tibial shaft fractures. In addition, our study supports the predictive value of a previous prognostic index, which inform discussion of prognosis following operative management of tibial fractures.

The Radiographic Union Score for Hip (RUSH): the use of a checklist to evaluate hip fracture healing improves agreement between radiologists and orthopedic surgeons.

OBJECTIVE: The assessment of fracture healing following intertrochanteric fracture fixation is highly variable with no validated standards. Agreement with respect to fracture healing following surgery is important for optimal patient management. The purpose of this study was to (1) assess reliability of intertrochanteric fracture healing assessment and (2) determine if a novel radiographic scoring system for hip fractures improves agreement between radiologists and orthopedic surgeons. MATERIALS AND METHODS: A panel of three radiologists and three orthopedic surgeons assessed fracture healing in 150 cases of intertrochanteric fractures at two separate time points to determine inter-rater and intra-rater agreement. Reviewers, blinded to the time after injury, first subjectively assessed overall healing using frontal and lateral radiographs for each patient at a single time point. Reviewers then scored each fracture using a Radiographic Union Score for Hip (RUSH) form to determine whether this improves agreement regarding hip fracture healing. RESULTS: Inter-rater agreement for the overall subjective impression of fracture healing between reviewer groups was only fair (intraclass coefficient [ICC] = 0.34, 95 % CI: 0.11-0.52. Use of the RUSH score improved overall agreement between groups to substantial (ICC = 0.66, 95 % CI: 0.53-0.75). Across reviewers, healing of the medial cortex and overall RUSH score itself demonstrated high correlations with overall perceptions of healing (r = 0.53 and r = 0.72, respectively). CONCLUSIONS: The RUSH score improves agreement of fracture healing assessment between orthopedic surgeons and radiologists, offers a systematic approach to evaluating intertrochanteric hip fracture radiographs, and may ultimately provide prognostic information that could predict healing outcomes in patients with femoral neck fractures.

Development and preliminary validation of a Function IndeX for Trauma (FIX-IT).

BACKGROUND: Assessing fracture healing in clinical trials is subjective. The new Function IndeX for Trauma (FIX-IT) score provides a simple, standardized approach to assess weight-bearing and pain in patients with lower extremity fractures. We conducted an initial validation of the FIX-IT score. METHODS: We conducted a cross-sectional study involving 50 patients with lower extremity fractures across different stages of healing to evaluate the reliability and preliminary validity of the FIX-IT score. Patients were independently examined by 2 orthopedic surgeons, 1 orthopedic fellow, 2 orthopedic residents and 2 research coordinators. Patients also completed the Short Form-36 version 2 (SF-36v2) questionnaire, and convergent validity was tested with the SF-36v2. RESULTS: For interrater reliability, the intraclass correlation coefficients ranged from 0.637 to 0.915. The overall interrater reliability for the total FIX-IT score was 0.879 (95% confidence interval 0.828-0.921). The correlations between the FIX-IT score and the SF-36 ranged from 0.682 to 0.770 for the physical component summary score, from 0.681 to 0.758 for the physical function subscale, and from 0.677 to 0.786 for the role-physical subscale. CONCLUSION: The FIX-IT score had high interrater agreement across multiple examiners. Moreover, FIX-IT scores correlate with the physical scores of the SF-36. Although additional research is needed to fully validate FIX-IT, our results suggest the potential for FIX-IT to be a reliable adjunctive clinician measure to evaluate healing in lower extremity fractures. LEVEL OF EVIDENCE: Diagnostic Study Level I.

CONTEXTE: Évaluer la guérison d'une fracture dans le cadre d'essais cliniques est un processus subjectif. Le nouveau score FIX-IT (pour Function IndeX for Trauma) constitue une approche simple et standardisée pour évaluer la mise en charge et la douleur chez les patients ayant subi une fracture d'un membre inférieur. Nous avons procédé à une validation initiale du score FIX-IT. MÉTHODES: Nous avons réalisé une étude transversale regroupant 50 patients qui ont subi une fracture d'un membre inférieur, à différents stades de la guérison, pour évaluer la fiabilité et la validité préliminaire du score FIX-IT. Les patients ont été examinés indépendamment par 2 chirurgiens orthopédistes, 1 chargé de cours en orthopédie, 2 médecins résidents en orthopédie et 2 coordonnateurs de recherche. Les patients ont aussi répondu au questionnaire SF-36v2 (Short Form-36 version 2) et la validité convergente a été vérifiée au moyen du SF-36v2. RÉSULTATS: En ce qui concerne la fiabilité interexaminateur, les coefficients de corrélation intraclasse ont varié de 0,637 à 0,915. La fiabilité interexaminateur pour le score FIX-IT total a été de 0,879 (intervalle de confiance de 95 % 0,828­0,921). Les corrélations entre le score FIX-IT et le SF-36 ont varié de 0,682 à 0,770 pour le score sommaire de la composante physique, de 0,681 à 0,758 pour la sous-échelle du fonctionnement physique et de 0,677 à 0,786 pour la sous-échelle du rôle physique. CONCLUSION: Le score FIX-IT a offert une concordance interexaminateur élevée entre les multiples examinateurs. De plus, les scores FIX-IT sont en corrélation avec les scores physiques obtenus au SF-36. Même s'il faudra approfondir la recherche pour valider complètement le score FIX-IT, nos résultats donnent à penser que cet indice pourrait être une mesure clinique d'appoint fiable pour évaluer la guérison des fractures de membres inférieurs. NIVEAU DE PREUVE: Étude diagnostique de niveau I.

Change in Gustilo-Anderson classification at time of surgery does not increase risk for surgical site infection in patients with open fractures: A secondary analysis of a multicenter, prospective randomized controlled trial.

Introduction: Open fractures represent a major source of morbidity. Surgical site infections (SSIs) after open fractures are associated with a high rate of reoperations and hospitalizations, which are associated with a lower health-related quality of life. Early antibiotic delivery, typically chosen through an assessment of the size and contamination of the wound, has been shown to be an effective technique to reduce the risk of SSI in open fractures. The Gustilo-Anderson classification (GAC) was devised as a grading system of open fractures after a complete operative debridement of the wound had been undertaken but is commonly used preoperatively to help with the choice of initial antibiotics. Incorrect preoperative GAC, leading to less aggressive initial management, may influence the risk of SSI after open fracture. The objectives of this study were to determine (1) how often the GAC changed from the initial to definitive grading, (2) the injury and patient characteristics associated with increases and decreases of the GAC, and (3) whether a change in GAC was associated with an increased risk of SSI. Methods: Using data from the FLOW trial, a large multicenter randomized study, we used descriptive statistics to quantify how frequently the GAC changed from the initial to definitive grading. We used regression models to determine which injury and patient characteristics were associated with increases and decreases in GAC and whether a change in GAC was associated with SSI. Results: Of the 2420 participants included, 305 participants had their preoperative GAC change (12.6%). The factors associated with upgrading the GAC (from preoperative score to the definitive assessment) included fracture sites other than the tibia, bone loss at presentation, width of wound, length of wound, and skin loss at presentation. However, initial misclassification of type III fractures as type II fractures was not associated with an increased risk of SSI (P = 0.14). Conclusions: When treating patients with open fracture wounds, surgeons should consider that 12% of all injuries may initially be misclassified when using the GAC, particularly fractures that have bone loss at presentation or those located in sites different than the tibia. However, even in misclassified fractures, it did not seem to increase the risk of SSI.

Prophylactic antibiotic regimens in tumor surgery (PARITY) survey.

BACKGROUND: Deep infection following endoprosthetic limb reconstruction for sarcoma of the long bones is a devastating complication occurring in 15% of sarcoma patients. Optimizing infection protocols and conducting definitive surgical trials are critical to improving outcomes. In this study, the PARITY (Prophylactic Antibiotic Regimens in Tumor Surgery) investigators aimed to examine surgeon preferences in antibiotic prophylaxis and perceptions about current evidence, as well as to ascertain interest in resolving uncertainty in the evidence with clinical trials. METHODS: We used a cross-sectional survey to examine current practice in the prescription of prophylactic antibiotics in Musculoskeletal Tumor Surgery. The survey was approved by our institution's Ethics Board and emailed to all Active Members of the Musculoskeletal Tumor Society (MSTS) and Canadian Orthopaedic Oncology Society (CANOOS). Survey answers were collected using an anonymous online survey tool. RESULTS: Of the 96 surgeons who received the questionnaire, 72 responded (75% response rate (% CI: 65.5, 82.5%)). While almost all respondents agreed antibiotic regimens were important in reducing the risk of infection, respondents varied considerably in their choices of antibiotic regimens and dosages. Although 73% (95% CI: 61, 82%) of respondents prescribe a first generation cephalosporin, 25% favor additional coverage with an aminoglycoside and/or Vancomycin. Of those who prescribe a cephalosporin, 33% prescribe a dosage of one gram for all patients and the reminder prescribe up to 2 grams based on body weight. One in three surgeons (95% CI: 25, 48%) believes antibiotics could be discontinued after 24 hours but 40% (95% CI: 30, 53%) continue antibiotics until the suction drain is removed. Given the ongoing uncertainty in evidence to guide best practices, 90% (95% CI: 81, 95%) of respondents agreed that they would change their practice if a large randomized controlled trial showed clear benefit of an antibiotic drug regimen different from what they are currently using. Further support for a clinical trial was observed by an overwhelming surgeon interest (87%; 95% CI: 77, 93%) in participating in a multi-center randomized controlled study. CONCLUSION: The current lack of guidelines for the prescription of prophylactic antibiotics in Musculoskeletal Tumor Surgery has left Orthopaedic Oncologists with varying opinions and practices. The lack of current evidence and strong surgeon support for participating in a definitive study provides strong rationale for clinical trials.

Does negative pressure wound therapy reduce the odds of infection and improve health-related quality of life in patients with open fractures?

AIMS: To evaluate the impact of negative pressure wound therapy (NPWT) on the odds of having deep infections and health-related quality of life (HRQoL) following open fractures. METHODS: Patients from the Fluid Lavage in Open Fracture Wounds (FLOW) trial with Gustilo-Anderson grade II or III open fractures within the lower limb were included in this secondary analysis. Using mixed effects logistic regression, we assessed the impact of NPWT on deep wound infection requiring surgical intervention within 12 months post-injury. Using multilevel model analyses, we evaluated the impact of NPWT on the Physical Component Summary (PCS) of the 12-Item Short-Form Health Survey (SF-12) at 12 months post-injury. RESULTS: After applying inverse probability treatment weighting to adjust for the influence of injury characteristics on type of dressing used, 1,322 participants were assessed. The odds of developing a deep infection requiring operative management within 12 months of initial surgery was 4.52-times higher in patients who received NPWT compared to those who received a standard wound dressing (95% confidence interval (CI) 1.84 to 11.12; p = 0.001). Overall, 1,040 participants were included in our HRQoL analysis, and those treated with NPWT had statistically significantly lower mean SF-12 PCS post-fracture (p < 0.001). These differences did not reach the minimally important difference for the SF-12 PCS. CONCLUSION: Our analysis found that patients treated with NPWT had higher odds of developing a deep infection requiring operative management within 12 months post-fracture. Due to possible residual confounding with the worst cases being treated with NPWT, we are unable to determine if NPWT has a negative effect or is simply a marker of worse injuries or poor access to early soft-tissue coverage. Regardless, our results suggest that the use of this treatment requires further evaluation. Cite this article: Bone Jt Open 2022;3(3):189-195.

Intimate Partner Violence During Recovery from an Orthopaedic Injury: An Exploratory, Prospective, Multicenter, Observational Cohort Study.

BACKGROUND: Orthopaedic injuries may lead to an increased incidence of intimate partner violence (IPV) during recovery as people dependent on others' help are at a higher risk for abuse. Additionally, there is a lack of understanding of how IPV affects injury recovery. In women being treated for an orthopaedic injury, we aimed to determine the number of new IPV disclosures in the 12 months after an injury and to explore the impact of IPV on recovery. METHODS: We enrolled 250 female participants from 6 orthopaedic fracture clinics in Canada, the Netherlands, Spain, and Finland. IPV disclosure and clinical outcomes were assessed at the initial visit and during the 12-month follow-up period. RESULTS: Of 250 participants, 81 (32.4% [95% confidence interval (CI), 26.6% to 38.2%]) had a history of IPV in their lifetime and disclosed this at their initial orthopaedic clinic appointment. Twenty-one participants (12.4% [95% CI, 7.5% to 17.8%]) who did not disclose abuse at the initial visit disclosed IPV during the follow-up. In our a priori unadjusted analysis, disclosure of IPV at the initial appointment or a subsequent follow-up appointment was associated with a 32% lower likelihood of returning to a pre-injury level of function with no restrictions regarding responsibilities at home (hazard ratio, 0.68 [95% CI, 0.46 to 0.99]; p = 0.046). Participants disclosing IPV had lower health-related quality of life on the EuroQol-5 Dimensions (EQ-5D) at the 6-month-follow-up, with adjusted mean differences of -5.3 (95% CI, -10.2 to -0.4, p = 0.04) for the visual analog scale and -0.06 (95% CI, -0.11 to -0.01; p = 0.02) for the Function Index. They also had lower Function Index scores at the final 12-month follow-up visit, with an adjusted mean difference of -0.06 (95% CI, -0.10 to -0.02; p = 0.006). CONCLUSIONS: A surprisingly high percentage of women disclosed IPV within 12 months after the injury. Our exploratory results suggest that women who disclose IPV may have lower health-related quality of life. This study supports the need to optimize orthopaedic clinics to provide appropriate support for asking about and assisting individuals who experienced IPV. Additional research is warranted to further explore these findings. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.