Is a Right Angle the Right Angle? Normal Coronal Radiographic Alignment in the Pediatric Finger Phalanges.

BACKGROUND: Quantifying pediatric phalanx fracture displacement requires understanding the normal radiographic alignment of pediatric phalanges, which has never been assessed in the coronal plane, although prior studies have assumed the articular surfaces and physes to be perpendicular to the diaphyses. This study tests the hypothesis that these relationships are not uniformly perpendicular and instead vary by digit and age. METHODS: Normal hand bone age radiographs were retrospectively reviewed from 40 males and 40 females 2 to 18 years old. For each finger proximal phalanx (P1) and middle phalanx (P2), 2 raters each measured twice the angle between the diaphysis and distal articular surface (D-DA), diaphysis and physis (D-P, when physis present), and diaphysis and proximal articular surface (D-PA). Intra-rater and inter-rater reliability were calculated with intraclass correlation coefficients. 95% confidence intervals were calculated for each angle for each digit, phalanx, age group, and sex to determine which angles ~90 degrees. Variability among ages and sex was assessed with analysis of variance. RESULTS: Intra-rater and inter-rater intraclass correlation coefficients were >0.90, except in P2 ∠D-DA in children under 8 years old with unossified P2 condyles. Overall, only 173 (47.8%) of 362 confidence intervals included 90 degrees. Three angles of the small finger (P1 ∠D-DA, P2 ∠D-P, P2 ∠D-PA) never ~90 degrees at any age or sex, with an average 10 degrees ulnar tilt of the small finger proximal interphalangeal joint. Of the 24 angles across digits and phalanges, 10 varied significantly with age, especially in the index and middle finger P1 where initially wedge-shaped epiphyses progressively became more symmetric with age. CONCLUSIONS: The coronal radiographic angles between the phalangeal diaphyses and articular surfaces or physes differ from 90 degrees more than half the time in pediatric fingers, and nearly half the angles vary by age. These findings demonstrate that the articular surfaces and physes of the pediatric finger phalanges are not uniformly perpendicular to the diaphyses, underscoring the need to consider the variability among digits, phalanges, ages and subjects. LEVEL OF EVIDENCE: Level IV.

Opioid Prescribing Patterns of Orthopedic Surgery Residents After Open Reduction Internal Fixation of Distal Radius Fractures.

PURPOSE: In many academic medical centers, resident physicians typically write initial opioid prescriptions, but little is known about their prescribing practices. We hypothesized that lower resident postgraduate year, residency-training program, and noncompletion of an opioid prescribing training would be factors associated with increased opioid prescribing by orthopedic residents after open reduction and internal fixation of distal radius fractures. METHODS: A survey was administered to all 135 residents from 4 orthopedic residency programs in a state located in the northeastern United States between August 2017 and November 2017. Respondents were asked to indicate the initial analgesia (quantity and duration) they would prescribe for a younger and older, otherwise healthy, opiate-naïve female patient after open reduction and internal fixation of a distal radius fracture. We analyzed the quantity of initial opioids prescribed in morphine milligram equivalents (MME) and number of days supplied. Three different measures of overprescribing were assessed: prescribing over 150 MME, 225 MME, or 7 days of opioids. RESULTS: The response rate was 63% (85 of 135 residents). Of all respondents, 36.5% of residents reported completion of an opioid training in the past. In terms of overprescribing by duration, 19% of residents prescribed more than 7 days of opioids. For overprescribing by quantity, 36% to 59% (depending on patient age) of residents prescribed more than 20 tablets of 5 mg oxycodone (150 MME) and 16% to 25% (depending on patient age) prescribed more than 30 tablets of 5 mg oxycodone (225 MME). In comparison with junior residents, senior residents were more likely to prescribe over 225 MME. CONCLUSIONS: After open reduction and internal fixation of distal radius fractures, 19% of orthopedic surgery residents would prescribe more than 7 days of prescription opioids, which is beyond the state law maximum. In addition, we found that less than half of residents had participated in an opioid training program. Our results highlight the need for continued resident guidance when prescribing. Enrollment in opioid prescribing training programs that have been shown to decrease prescribed opioid quantities while still effectively managing patient pain is probably important. CLINICAL RELEVANCE: This study describes the opioid prescribing practices and prior training of orthopedic residents. It highlights an opportunity for increased involvement in educational programs on opioid prescribing that better align with published recommendations/guidelines.

Advantages of a New Low-Cost Negative Pressure Wound Therapy Using the "Turtle VAC": A Case Series.

CASE: We present a clinical case and technique guide demonstrating the use and effectiveness of a novel, low-cost negative pressure wound therapy (NPWT) device to achieve soft-tissue coverage in a 34-year-old patient with failed rotational flap and Masquelet technique on infected tibial nonunion. Local debridement was executed, NPWT initiated, and treatment culminated with complete wound healing. CONCLUSION: The "Turtle VAC" offers an effective low-cost alternative to commercially vacuum-assisted closure systems for post-traumatic wounds in low-resource setting of Haiti. Its use of available equipment makes NPWT accessible and can function as a bridge to definitive closure when primary wound closure is not possible and/or between debridement procedures.

Implementation and Impact Evaluation of a Virtual Orthopaedic Continuing Medical Education Conference in a Low-Resource Country.

OBJECTIVE: The Haitian Annual Assembly of Orthopaedic Trauma (HAAOT) is an annual continuing medical education (CME) conference for Haitian orthopedists and trainees converted to a pilot virtual format in 2020 due to the COVID-19 pandemic. We evaluated this virtual format's effectiveness at teaching, facilitating bilingual discussion, and encouraging cross-cultural exchange of experiences - all aimed at improving orthopedic knowledge in a low-resource country like Haiti. DESIGN: Planned collaboratively between North American and Haitian colleagues, the conference involved 4 bilingual weekly Zoom meetings comprised of 4 to 6 prerecorded presentations and live-translated discussion. Pre- and postmeeting knowledge assessments in French (Haitian language of medical instruction) were administered weekly with results compared via 2-sample t-tests. An online postconference survey evaluated attendee satisfaction with the virtual format. SETTING: Virtual. PARTICIPANTS: Weekly attendance involved approximately 50 Haitian orthopedists and trainees, with 20 to 25 completing pre- and postmeeting assessments. RESULTS: Statistically significant increases between pre/post scores were seen during 3 of 4 sessions. Session-wide significant score increases occurred for residents and attending surgeons with <10 years of experience. 85.7% of attendees reported the virtual platform exceeded expectations and 100% indicated likely or extremely likely participation in further virtual events. CONCLUSIONS: The pilot virtual HAAOT was extremely well received with high desire for future sessions. Beyond short-term knowledge retention among attendees, nonmeasurable benefits included collaboration between orthopedists and trainees in the United States, Canada, United Kingdom, Haiti, and Burkina Faso. As COVID-19 spurs online learning in high-income nations, the successful low-resource context adjustments and local partnership underlying this model attest that travel restrictions need not impede delivery of virtual CME conferences in lower-income nations. Attendee learning and the decreased cost and travel requirements allude to this platform's sustainability and reproducibility in facilitating future international education and capacity building. Further studies will assess long-term retention of presented material.

Efficacy of antifibrinolytics in pediatric orthopedic surgery: a systematic review and meta-analysis.

Antifibrinolytics (AFs) stabilize blood clot formation and reduce bleeding. The purpose of this systematic review and meta-analysis was to determine the impact of AF use on intraoperative blood loss and the need for blood transfusion in pediatric orthopedic surgery. A systematic review was performed using Medline and Embase to identify studies that utilized AFs during pediatric orthopedic surgery. The primary outcome measure was intraoperative blood loss in ml. Secondary outcomes included blood transfusion and thromboembolic events. Pooled estimates were derived from a random-effects model. Heterogeneity was assessed using the Cochrane Q and I statistic. Meta-regression assessed if age or study quality modified the effect of AFs on blood loss. Publication bias was assessed using a funnel plot, Egger regression analysis, and the Kendall τ-test. Twenty studies, with a total of 1356 patients, were included. The mean difference in intraoperative blood loss was 653 ml [95% confidence interval (CI): 464-842 ml, P < 0.001]. Similarly, the mean difference in percent of blood volume lost was 22% less in patients treated with AFs compared with controls (95% CI: 12-32, P < 0.001). Patients treated with AFs had a lower odds of transfusion compared to controls (OR: 0.324; 95% CI: 0.105-0.997, P = 0.049). The use of AF in pediatric orthopedic surgery results in decreased intraoperative blood loss and a lower risk of blood transfusion. The majority of studies included involve spine surgery; the benefits of AFs in extremity surgery in the pediatric population have yet to be delineated. Level of Evidence: Level II.

Consideration of medial anatomical structures at risk when placing quadricortical syndesmotic fixation: A cadaveric study.

BACKGROUND: Surgical fixation of syndesmotic instability using quadricortical fixation, whether screws or suture-button devices, places structures on the medial side of the tibia at iatrogenic risk. This study aims to radiographically map the anatomic course of structures on the medial aspect of the distal tibia to be able to at-risk zones (ARZs) for syndesmotic fixation. METHODS: Eighteen fresh-frozen cadaveric ankle specimens were dissected. The saphenous neurovascular bundle (SNVB) and the posterior tibial tendon (PTT) were identified and marked with copper wiring. Standardized and calibrated lateral radiographs of the distal tibia and fibula were analyzed using a grid system consisting of 3 columnar zones from anterior to posterior and five 1-cm rows to chart the anatomic course of the SNVB and the PTT. RESULTS: The SNVB was located in the more anterior zones (1, 2, or anterior to Zone 1) in 97.3% of specimens. The SNVB traversed from posterior to anterior as it descended proximal to distal. The PTT was found in Zone 3 (most posterior zone) for all specimens. The PTT was noted to pass behind (radiographically overlap) the tibia in 83.3% (15 of 18) of specimens between 1 and 3 cm above the tibiotalar joint. CONCLUSIONS: Placement of quadricortical syndesmotic fixation places structures on the medial ankle at risk. The SNVB is at considerable risk along the anterior course of the distal tibial while the PTT is only at risk in zone 3 at the distal extent of the tibia.

Cross-Cultural Comparison of Nonopioid and Multimodal Analgesic Prescribing in Orthopaedic Trauma.

BACKGROUND: After musculoskeletal injury, US providers prescribe opioids more frequently and at higher dosages than prescribers in the Netherlands and Haiti; however, the extent of variation in nonopioid analgesic prescribing is unknown. The aim of our study was to evaluate how nonopioid prescribing by orthopaedic residents varies by geographic context. METHODS: Orthopaedic residents in three countries in which residents are the primary prescribers of postoperative analgesia in academic medical centers (Haiti, the Netherlands, and the United States) responded to surveys using vignette-based musculoskeletal trauma case scenarios. The residents chose which medications they would prescribe for postdischarge analgesia. We quantified the likelihood and dose of acetaminophen or a nonsteroidal anti-inflammatory drug prescription. We constructed multivariable regressions with generalized estimating equations to describe differences in nonopiate prescription according to country, the resident's sex and training year, and the injury site and age in the test cases. RESULTS: Compared with residents from the United States, residents from Haiti were more likely to prescribe nonopioids (odds ratio, 3.22 [confidence interval, 1.94 to 5.34], P < 0.0001) and residents from the Netherlands nearly always prescribed nonopioids. Of those cases where one or more opioid was prescribed, providers also prescribed a nonopioid (acetaminophen or nonsteroidal anti-inflammatory drug) in 345/603 (57.2%) of US, 152/152 (100%) of Dutch, and 69/97 (71.1%) of Haitian cases (Fisher exact test P value <0.0001). Finally, providers prescribed only nonopioids for pain control in 3/348 (0.86%) of US, 32/184 (17.4%) of Dutch, and 107/176 (60.8%) of Haitian cases (Fisher exact test P < 0.0001). CONCLUSIONS: When comparing multimodal analgesic patterns, US prescribers prescribed nonopioid analgesics less frequently than prescribers in two other countries, one low income and one high income, either in isolation or in conjunction with opioids.

The Continued Utility and Viability of Dakin's Solution in Both High- and Low-resource Settings.

Healthcare is expensive and often inaccessible to many. As a result, surgeons must consider simple, less expensive interventions when possible. For wound care, an older but quite effective cleaning agent is Dakin's solution (0.5% sodium hypochlorite), an easily made mixture of 100 milliliters (ml) bleach with 8 teaspoons (tsp) baking soda into a gallon of clean water or 25 ml bleach and 2 tsp baking soda into a liter of water. Gauze is then wet with this solution, placed on the wound, and replaced every 24 hours as needed. Our team of surgeons in Haiti and the United States is currently using Dakin's solution for wound care following orthopedic surgery and finds it to be a low-cost, safe, and effective treatment for post-surgical wound care for both resource-limited and non-resource strained environments. This report aims to update the current literature and encourage the consideration of Dakin's solution for modern wound care.

Education Improves Musculoskeletal Radiology Interpretation by Trainees in a Low-Resource Setting.

OBJECTIVE: The aims of this study were to assess baseline musculoskeletal radiology knowledge among Haitian orthopedists and to determine the impact of an adult and pediatric musculoskeletal radiology lecture series. DESIGN: Participants were given lectures reviewing normal and abnormal elbow radiographs and received assessments before and after the intervention. Bivariate and multivariate analyses were used to identify factors associated with baseline and postintervention scores. SETTING: This study was carried out as part of the 2018 Haitian Annual Assembly of Orthopaedic Trauma. This is an annual continuing medical educational conference in the capital city of Port-au-Prince open to all Haitian orthopedic surgeons and associated care providers, with a strong focus on resident training. PARTICIPANTS: Haitian orthopedic surgery residents and surgeons attending the 2018 Haitian Annual Assembly of Orthopaedic Trauma. RESULTS: Thirty-seven residents and faculty consented to participate in this study and 32 (86.5%) were male with a median age of 33 (interquartile rage: 30-35). On multivariate analysis controlling for the title (resident versus attending), total years of orthopedics (beginning of residency and beyond), and formal radiology teaching in medical school or residency, conference attendance in the past was significantly associated with higher preintervention assessment scores (odds ratio = 1.24, 95% confidence interval = 1.06-1.44, p = 0.010]. The mean total preintervention accuracy for correctly identification of pathology, if present, was 70% compared to 83% at the postassessment (p < 0.001). CONCLUSIONS: Overall, this study demonstrates that a brief lecture series at a continuing medical conference in Port-au-Prince, Haiti improved upper extremity radiographic interpretation based on pre and postassessments, and that prior conference attendance may be associated with higher baseline scores.

Cross-Cultural Comparison of Postoperative Discharge Opioid Prescribing After Orthopaedic Trauma Surgery.

BACKGROUND: The extent of variation in analgesic prescribing following musculoskeletal injury among countries and cultural contexts is poorly understood. Such an understanding can inform both domestic prescribing and future policy. The aim of our survey study was to evaluate how opioid prescribing by orthopaedic residents varies by geographic context. METHODS: Orthopaedic residents in 3 countries in which residents are the primary prescribers of postoperative analgesia in academic medical centers (Haiti, the Netherlands, and the U.S.) responded to surveys utilizing vignette-based musculoskeletal trauma case scenarios. The residents chose which medications they would prescribe for post-discharge analgesia. We standardized opioid prescriptions in the surveys by conversion to morphine milligram equivalents (MMEs). We then constructed multivariable regressions with generalized estimating equations to describe differences in opiate prescription according to country, the resident's sex and training year, and the injury site and age in the test cases. RESULTS: U.S. residents prescribed significantly more total MMEs per case (mean [95% confidence interval] = 383 [331 to 435]) compared with residents from the Netherlands (229 [160 to 297]) and from Haiti (101 [52 to 150]) both overall (p < 0.0001) and for patients treated for injuries of the femur (452 [385 to 520], 315 [216 to 414], and 103 [37 to 169] in the U.S., the Netherlands, and Haiti, respectively), tibial plateau (459 [388 to 531], 280 [196 to 365], and 114 [46 to 183]), tibial shaft (440 [380 to 500], 294 [205 to 383], and 141 [44 to 239]), wrist (239 [194 to 284], 78 [36 to 119], and 63 [30 to 95]), and ankle (331 [270 to 393], 190 [100 to 280], and 85 [42 to 128]) (p = 0.0272). U.S. residents prescribed significantly more MMEs for patients <40 years old (432 [374 to 490]) than for those >70 years old (327 [270 to 384]) (p = 0.0019). CONCLUSIONS: Our results demonstrate greater prescribing of postoperative opioids at discharge in the U.S. compared with 2 other countries, 1 low-income and 1 high-income. Our findings highlight the high U.S. reliance on opioid prescribing for postoperative pain control after orthopaedic trauma. CLINICAL RELEVANCE: Our findings point toward a need for careful reassessment of current opioid prescribing habits in the U.S. and demand reflection on how we can maximize effectiveness in pain management protocols and reduce provider contributions to the ongoing opioid crisis.

Clinical outcomes and risk-factor analysis of the Ponseti Method in a low-resource setting: Clubfoot care in Haiti.

PURPOSE: The Ponseti Method has dramatically altered the management of clubfoot, with particular implications for limited-resource settings. We sought to describe outcomes of care and risk factors for sub-optimal results using the Ponseti Method in Haiti. METHODS: We conducted a records review of patients presenting from 2011-2015 to a CURE Clubfoot clinic in Port-au-Prince, Haiti. We report patient characteristics (demographics and clinical), treatment patterns (cast number/duration and tenotomy rates), and outcomes (relapse and complications). We compared treatment with benchmarks in high-income nations and used generalized linear models to identify risk factors for delayed presentation, increased number of casts, and relapse. RESULTS: Amongst 168 children, age at presentation ranged from 0 days (birth) to 4.4 years, 62% were male, 35% were born at home, 63% had bilateral disease, and 46% had idiopathic clubfeet. Prior treatment (RR 6.33, 95% CI 3.18-12.62) was associated with a higher risk of delayed presentation. Risk factors for requiring ≥ 10 casts included having a non-idiopathic diagnosis (RR 2.28, 95% CI 1.08-4.83) and higher Pirani score (RR 2.78 per 0.5 increase, 95% CI 1.17-6.64). Female sex (RR 1.54, 95% CI 1.01-2.34) and higher Pirani score (RR 1.09 per 0.5 increase, 95% CI 1.00-1.17) were risk factors for relapse. Compared to North American benchmarks, children presented later (median 4.1 wks [IQR 1.6-18.1] vs. 1 wk), with longer casting (12.5 wks [SD 9.8] vs. 7.1 wks), and higher relapse (43% vs. 22%). CONCLUSIONS: Higher Pirani score, prior treatment, non-idiopathic diagnosis, and female sex were associated with a higher risk of sub-optimal outcomes in this low-resource setting. Compared to high-income nations, serial casting began later, with longer duration and higher relapse. Identifying patients at risk for poor outcomes in a low-resource setting can guide counseling, program development, and resource allocation.

Cost-utility studies in upper limb orthopaedic surgery: a systematic review of published literature.

AIMS: The aim of this study was to assess the quality and scope of the current cost-effectiveness analysis (CEA) literature in the field of hand and upper limb orthopaedic surgery. MATERIALS AND METHODS: We conducted a systematic review of MEDLINE and the CEA Registry to identify CEAs that were conducted on or after 1 January 1997, that studied a procedure pertaining to the field of hand and upper extremity surgery, that were clinical studies, and that reported outcomes in terms of quality-adjusted life-years. We identified a total of 33 studies that met our inclusion criteria. The quality of these studies was assessed using the Quality of Health Economic Analysis (QHES) scale. RESULTS: The mean total QHES score was 82 (high-quality). Over time, a greater proportion of these studies have demonstrated poorer QHES quality (scores < 75). Lower-scoring studies demonstrated several deficits, including failures in identifying reference perspectives, incorporating comparators and sensitivity analyses, discounting costs and utilities, and disclosing funding. CONCLUSION: It will be important to monitor the ongoing quality of CEA studies in orthopaedics and ensure standards of reporting and comparability in accordance with Second Panel recommendations. Cite this article: Bone Joint J 2018;100-B:1416-23.

The Cost-Effectiveness of Surgical Fixation of Distal Radial Fractures: A Computer Model-Based Evaluation of Three Operative Modalities.

BACKGROUND: There is no consensus on the optimal fixation method for patients who require a surgical procedure for distal radial fractures. We used cost-effectiveness analyses to determine which of 3 modalities offers the best value: closed reduction and percutaneous pinning, open reduction and internal fixation, or external fixation. METHODS: We developed a Markov model that projected short-term and long-term health benefits and costs in patients undergoing a surgical procedure for a distal radial fracture. Simulations began at the patient age of 50 years and were run over the patient's lifetime. The analysis was conducted from health-care payer and societal perspectives. We estimated transition probabilities and quality-of-life values from the literature and determined costs from Medicare reimbursement schedules in 2016 U.S. dollars. Suboptimal postoperative outcomes were determined by rates of reduction loss (4% for closed reduction and percutaneous pinning, 1% for open reduction and internal fixation, and 11% for external fixation) and rates of orthopaedic complications. Procedural costs were $7,638 for closed reduction and percutaneous pinning, $10,170 for open reduction and internal fixation, and $9,886 for external fixation. Outputs were total costs and quality-adjusted life-years (QALYs), discounted at 3% per year. We considered willingness-to-pay thresholds of $50,000 and $100,000. We conducted deterministic and probabilistic sensitivity analyses to evaluate the impact of data uncertainty. RESULTS: From the health-care payer perspective, closed reduction and percutaneous pinning dominated (i.e., produced greater QALYs at lower costs than) open reduction and internal fixation and dominated external fixation. From the societal perspective, the incremental cost-effectiveness ratio for closed reduction and percutaneous pinning compared with open reduction and internal fixation was $21,058 per QALY and external fixation was dominated. In probabilistic sensitivity analysis, open reduction and internal fixation was cost-effective roughly 50% of the time compared with roughly 45% for closed reduction and percutaneous pinning. CONCLUSIONS: When considering data uncertainty, there is only a 5% to 10% difference in the frequency of probability combinations that find open reduction and internal fixation to be more cost-effective. The current degree of uncertainty in the data produces difficulty in distinguishing either strategy as being more cost-effective overall and thus it may be left to surgeon and patient shared decision-making. LEVEL OF EVIDENCE: Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Self-Reported Needs Assessment Survey of Pediatric Orthopaedic Education in Haiti.

OBJECTIVE: The burden of musculoskeletal disease remains high in low-income countries, with a high rate of pediatric disease. Efforts continue for orthopedic education, but there is little guidance on local needs and desires. Our aim was to determine the specific content and modalities that would be most useful for pediatric orthopedic educational programs abroad, and we demonstrate a practical method of identifying country-specific educational deficits through a self-reported needs survey in Haiti. DESIGN: A cross-sectional survey was administered using an automated response system. We obtained demographic information as well as training and practice patterns, comfort levels with pediatric diagnoses, and desired topics for education using a 5-point Likert Scale. SETTING: Haitian Annual Assembly for Orthopaedic Trauma (HAAOT), the only national, continuing medical education conference for orthopedic providers in Haiti. PARTICIPANTS: Of 60 eligible participants, 51 were included in the final analysis. RESULTS: Time spent on pediatric orthopedics varied widely, centered at 10% to 25%. Median comfort level with pediatric orthopedics was 3 of 5. Skills with lowest self-reported competence included spica casting, clubfoot casting, and management of supracondylar humerus fractures. Skills with highest self-reported competence were long-leg casting and Salter-Harris classification. Modes of education highly requested included didactics/lectures, hands-on sessions, dedicated rotations, and exchanges with foreign peers/mentors. Diagnoses most encountered were osteomyelitis, trauma, and clubfoot; lowest comfort levels were in neuromuscular, spine, lower extremity deformity, congenital hip, and clubfoot; and most requested for future teaching were congenital hip, neuromuscular, and spine. CONCLUSIONS: Haitian orthopedic providers express a strong desire and need for ongoing pediatric orthopedic education. They describe a high prevalence of trauma and infection, but convey a requirement for more comprehensive, multimodal teaching that also includes congenital deformities/dysplasias, neuromuscular, and spine. Our results demonstrate the importance of assessing country-specific needs and involving local care providers in curriculum development.

Iatrogenic fracture gapping during fixation of Jones fractures: Anatomic and mechanical considerations in a cadaveric model.

BACKGROUND: Surgical fixation of Jones fractures is often recommended to facilitate recovery and achieve union. Iatrogenic fracture displacement during intramedullary screw fixation is a commonly encountered technical issue. This may be related to fracture location in relation to the surrounding ligamentous attachments, namely the robust intermetatarsal ligaments found at the proximal articulation of the 4th and 5th metatarsals. This study examines the relationship between fracture line and its location in regards to the surrounding ligamentous structures and its effect on Jones fracture displacement, reduction and fixation in a cadaveric model. METHODS: Eighteen fresh-frozen cadaveric feet were dissected with preservation of all ligamentous attachments. Given the similar anatomic distal extent of the dorsal and plantar intermetatarsal ligaments on the 5th metatarsal, measurements were obtained detailing the anatomic position of the dorsal intermetatarsal ligament (DIL) only. The specimens were divided into two groups with modelled fractures created at the 4th & 5th metatarsal articulation proximal to the distal extent of the DIL (Group 1) or just distal to the DIL (Group 2). Fractures were fixed in standard fashion with serial fluoroscopic images obtained to study fracture gapping and rotation. RESULTS: There was approximately 5 mm of fracture gapping created iatrogenically during tapping with no statistically significant differences between Group 1 and Group 2 (4.53 mm versus 5.25 mm, p = 0.5430). The distal aspect of the DIL was anatomically located 2.77 mm (Range 1.58 mm-4.46 mm) distal to the 4th & 5th metatarsal articulation. CONCLUSIONS: Considerable iatrogenic fracture gapping occurs during intramedullary screw fixation of Jones fractures in a cadaveric model regardless of fracture location in relation to the intermetatarsal ligamentous attachments. Specific techniques may be required to maintain anatomic alignment during tapping and screw fixation to prevent iatrogenic displacement. LEVEL OF EVIDENCE: V, Expert Opinion.

Comparison of hydrogels in the in vivo formation of tissue-engineered bone using mesenchymal stem cells and beta-tricalcium phosphate.

Availability of grafts and morbidity at the donor site limit autologous transplantation in patients requiring bone reconstruction. A tissue-engineering approach can overcome these limitations by producing bone-like tissue of custom shape and size from isolated cells. Several hydrogels facilitate osteogenesis on porous scaffolds; however, the relative suitability of various hydrogels has not been rigorously assessed. Fibrin glue, alginate, and collagen I hydrogels were mixed with swine bone marrow-derived differentiated mesenchymal stem cells (MSCs), applied to 3-dimensionally printed porous beta-tricalcium phosphate (beta-TCP) scaffolds and implanted subcutaneously in nude mice. Although noninvasive assessment of osteogenesis in 3 dimensions is desirable for monitoring new bone formation in vivo, correlations with traditional histological and mechanical testing need to be established. High-resolution volumetric computed tomography (VCT) scanning, histological examination, biomechanical compression testing, and osteonectin (ON) expression were performed on excised scaffolds after 1, 2, 4, and 6 weeks of subcutaneous implantation in mice. Statistical correlation analyses were performed between radiological density, stiffness, and ON expression. Use of collagen I as a hydrogel carrier produced superior bone formation at 6 weeks, as demonstrated using VCT scanning with densities similar to native bone and the highest compression values. Continued contribution of the seeded MSCs was demonstrated using swine-specific messenger ribonucleic acid probes. Radiological density values correlated closely with the results of histological and biomechanical testing and ON expression. High-resolution VCT is a promising method for monitoring osteogenesis.

Tranexamic Acid in Orthopaedic Trauma Surgery: A Meta-Analysis.

AIM: To systematically review and quantify the efficacy of tranexamic acid (TXA) use in reducing the risk of receiving a blood transfusion in patients undergoing orthopaedic trauma surgery, in reducing blood loss, and risk of thromboembolic events. METHODS: A systematic literature search was performed using MEDLINE, Embase, ClinicalTrials.gov, and conference proceeding abstracts from 2014 to 2016. A minimum of 2 reviewers screened each study and graded quality. The primary outcome measure was the risk of receiving a blood transfusion in the TXA group versus control. A meta-analysis was performed to construct a combined odds ratio (OR) of receiving a blood transfusion, mean difference (MD) of blood loss, and OR of thromboembolic events. RESULTS: Twelve studies were included in the quantitative analysis (1,333 patients). The risk of blood transfusion was significantly less in patients who were administered TXA compared with controls [OR 0.407; 95% confidence interval (CI) 0.278-0.594, I = 34, Q = 17, P ≤ 0.001]. There was significantly less blood loss in the TXA group compared with controls, as the mean difference was 304 mL (95% CI, 142-467 mL) (I = 94, Q value = 103, P < 0.001). There was no significant difference in risk of symptomatic thromboembolic events (OR 0.968; 95% CI, 0.530-1.766, I = 0, Q value = 5, P = 0.684). CONCLUSIONS: In patients with orthopaedic trauma, TXA reduces the risk of blood transfusion, reduces perioperative blood loss, and has no significant effect on the risk of symptomatic thromboembolic events. More high-quality studies are needed to ensure the safety of the drug in these patients. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

A Randomized Controlled Pilot Study of Educational Techniques in Teaching Basic Arthroscopic Skills in a Low-income Country.

BACKGROUND: Little is known about how to introduce complex technologies like arthroscopy into low-income countries. Thus, we compared low- versus high-resource intensive methods of teaching basic arthroscopic skills in a randomized controlled trial in Haiti. METHODS: Forty-eight Haitian orthopaedic surgeons and residents attending an orthopaedic conference in Haiti were block randomized to receive instruction through a composite video (Control) or a composite video plus hands-on teaching with an expert visiting surgeon (Intervention). A low-fidelity surgical simulator tested visualization and triangulation skills. Participants completed a pre- and post-test where the goal was to sequentially tap the most numbers in 2.5 minutes. Outcome metrics included highest tapped number, number of errors, visualization loss, and number of lookdowns. Multivariate linear regression was used to confirm randomization and compare outcomes between groups. RESULTS: Seventy-five percent of initially randomized attendees participated with similar attrition rates between both groups. All participants who performed a pre-test completed a post-test. In terms of highest tapped number, treatment and control groups significantly improved compared to pre-test scores, with mean improvement of 3.2% (P=0.007) and 2.2% (P=0.03), respectively. Improvement between treatment and control groups was not statistically different (P=0.4). No statistically significant change was seen with regard to other metrics. CONCLUSION: We describe a protocol to introduce basic arthroscopic skills in a low-income country using a low-resource intensive teaching method. However, this method of learning may not be optimal given the failure to improve in all outcome measures.

Diagnostic Imaging Strategies for Occult Hip Fractures: A Decision and Cost-Effectiveness Analysis.

OBJECTIVE: Hip fractures cause significant morbidity and mortality. Determining the optimal diagnostic strategy for the subset of patients with potential occult hip fracture remains challenging. We determined the most cost-effective strategy for the diagnosis of occult hip fractures from the choices of performing only computed tomography (CT), performing only magnetic resonance imaging (MRI), performing CT and if negative performing MRI (MRI-selective strategy) or discharging the patient without advanced imaging. METHODS: We developed a decision-analytic model to compare outcomes and costs of different diagnostic strategies for the diagnosis of an occult hip fracture from a societal perspective. Model inputs were derived from charge data, Medicare reimbursements, and the literature. Strategies with an incremental cost-effectiveness ratio (ICER) below $100,000 per quality-adjusted life-year (QALY) gained were considered cost-effective. We tested the robustness of our results using probabilistic sensitivity analysis. RESULTS: Compared to a CT strategy, MRI provides an additional 0.05 QALY at an incremental cost of $1,227 and ICER of $25,438/QALY. For facilities without MRI capability, if the cost of transfer is below $1,228, transferring the patient to a MRI-capable facility is the most cost-effective strategy. Above this cost, employing a CT and if negative transfer to a MRI-capable facility strategy was more cost-effective. When the cost of a transfer reached more than $4,039, it became more cost-effective to only obtain a CT. CONCLUSION: MRI is a cost-effective strategy for the diagnosis of an occult hip fracture. For facilities without MRI capability, the most cost-effective strategy depends on the cost of the interfacility transfer.