Leash-related injuries associated with dog walking: an understudied risk for dog owners?

The topic of dog-walking injuries has recently gained notoriety through major media outlets in North America, including the Washington Post, NPR, and US News and World Report. In this review, we have compiled data from the main studies published in the past 2 decades that assess the incidence, demographics, and injury patterns related to dog leash walking. The available papers indicate that dog leash-related injuries have increased, particularly among women over 65. The most common causes of injury are dog-pulling behavior, which can result in tripping or tangling, with or without a fall, as well as upper extremity injuries. However, there is a lack of information regarding dog size, breed, training status, the type of leash used at the time of injury, and the role each factor may have in the incidence of injuries. The available data did not allow for evaluation of the impact of weather conditions on injury incidence. Information about the involved dogs, type of lead device, and weather conditions could be useful in identifying risk factors associated with dog ownership and guide prospective pet owners and their families to mitigate the risk of injuries.

The Canadian Orthopaedic Trauma Society.

AIMS: This study reviews the past 30 years of research from the Canadian Orthopedic Trauma Society (COTS), to identify predictive factors that delay or accelerate the course of randomized controlled trials in orthopaedic trauma. METHODS: We conducted a methodological review of all papers published through the Canadian Orthopaedic Trauma Society or its affiliates. Data abstracted included: year of publication; journal of publication; study type; number of study sites; sample size; and achievement of sample size goals. Information about the study timelines was also collected, including: the date of study proposal to COTS; date recruitment began; date recruitment ended; and date of publication. RESULTS: In total, 22 studies have been published through the COTS working group, 13 of which are randomized controlled trials (RCTs). In total, 1,423 individual patients have been involved in COTS studies, a mean of 110 patients per trial (22 to 424). Each study was conducted across a mean of approximately six centres (1 to 11) and took nearly ten years (mean 119.9 months (59 to 188)) from presentation of concept to publication. The mean length of enrolment was 63 months (26 to 113) and the mean time from cessation of enrolment to publication 51 months (19 to 78). Regardless of sample size, the only factor associated with a decreased length of enrolment was a higher number of clinical sites (p = 0.041). Neither study sample size nor length of enrolment were associated with total time to publication. CONCLUSION: Over the last three decades, COTS has developed a multinational strategy to produce high-quality evidence in the field of orthopaedic trauma through 13 multicentre RCTs. Future efficiencies can be realized by recruitment of more clinical sites, improving connectivity between the sites, and the promotion of national streamlined ethics processes. Cite this article: Bone Joint J 2021;103-B(5):898-901.

The AO trauma CPP bone infection registry: Epidemiology and outcomes of Staphylococcus aureus bone infection.

Bone infection represents a serious complication of orthopedic surgery and Staphylococcus aureus is the most common pathogen. To improve the understanding of host-pathogen interaction, we developed a biospecimen registry (AO Trauma CPP Bone Infection Registry) to collect clinical data, bacterial isolates, and serum from patients with S. aureus bone infection. A prospective multinational registry with a 12-month follow-up was created to include adult patients (18 years or older) with culture-confirmed S. aureus infection in long bones after fracture fixation or arthroplasty. Baseline patient attributes and details on infections and treatments were recorded. Blood and serum samples were obtained at baseline, 6, and 12 months. Patient-reported outcomes were collected at 1, 6, and 12 months. Clinical outcomes were recorded. Two hundred and ninety-two patients with fracture-related infection (n = 157, 53.8%), prosthetic joint infection (n = 86, 29.5%), and osteomyelitis (n = 49, 16.8%) were enrolled. Methicillin-resistant S. aureus was detected in 82 patients (28.4%), with the highest proportion found among patients from North American sites (n = 39, 48.8%) and the lowest from Central European sites (n = 18, 12.2%). Patient outcomes improved at 6 and 12 months in comparison to baseline. The SF-36 physical component summary mean (95% confidence interval) score, however, did not reach 50 at 12 months. The cure rate at the end of the study period was 62.1%. Although patients improved with treatment, less than two-thirds were cured in 1 year. At 12-month follow-up, patient-reported outcome scores were worse for patients with methicillin-resistant S. aureus infections.

Does 3D CT reconstruction help the surgeon to preoperatively assess calcaneal fractures?

BACKGROUND: With the advent of 3D volume rendered CT scans, more information is potentially available to aid the surgeon in complex calcaneal fractures. The primary aim was to determine if there is a difference in inter-observer and intra-observer reliability of 3D CT reconstructions compared to 2D CTs of calcaneus fractures based on classification, identification of specific fracture characteristics and proposed treatment. It is hypothesized that the correlation will be greater between experienced surgeons and trainees when using 3D CT. As a secondary aim, the authors wished to investigate the surgeons' satisfaction with 3D CT. PATIENTS AND METHODS: There were six raters, split into 2 groups: high and low surgical experience. Both 2D and 3D scans (10 patients) were reviewed by each rater by filling out a validated questionnaire. This sitting was over a period of six months and all scans were sent separately and randomly by our research coordinator. This process was repeated after a four-week break. RESULTS: The overall evaluation and satisfaction of CT scans of calcaneal fractures was improved by the additional use of volume rendered 3D images. Inexperienced surgeons benefited more than experienced surgeons in terms of reliabilities with fracture configuration. 3D CTs were more likely to change the surgeons' operative strategy. The consistency of deciding on the fracture classification and satisfaction was more uniform between all the raters when 3D CT was used. CONCLUSION: Inter-observer and intra-observer reliability of 3D CT reconstructions compared to 2D CTs of calcaneus fractures was greater based on classification, identification of specific fracture characteristics and proposed treatment. Inexperienced surgeons were more consistent when interpreting the scans using 3D CTs (improved inter-observer reliability) and were always more satisfied using the 3D CTs. As there is no extra cost or radiation exposure, we propose that 3D CTs may be valuable with preoperative teaching and planning.

A sub-meniscal arthrotomy improves the medium-term patient outcome of tibial plateau fractures.

PURPOSE: This trial was conducted to determine the medium-term functional outcome of displaced tibial plateau fracture patients treated with closed fluoroscopic assisted reduction and internal fixation (CRIF) versus patients treated with standard open reduction with sub-meniscal arthrotomy and internal fixation (ORIF). METHODS: A prospective trial was conducted in adult patients with displaced AO/OTA 41 B and 41 C tibial plateau fractures. Patients were assigned to treatment based upon the standard treatment of the surgeon involved following the call schedule for the day, either CRIF or ORIF. Postoperative radiographs and CT were performed on all patients and patients were followed for a minimum of 2 years. Primary outcome measures were the KOOS, SMFA and SF-36. RESULTS: Seventy patients were recruited with 2 year follow-up on 35 patients in the CRIF group and 27 patients in the ORIF group. Postoperative CT scans showed that reductions were better with the ORIF group especially in the posterolateral quadrant as compared to the CRIF group. The frequency of mal-reductions was higher in the CRIF group. The KOOS, at two years, showed that the CRIF had significantly less good outcomes in the subcategories of SPORT (p = 0.03) and QOL (p = 0.01) measurements. CONCLUSIONS: ORIF with a sub-meniscal arthrotomy provides better quality reductions and better medium-term results as compared to CRIF for tibial plateau fractures. This may provide more long-term benefit from osteoarthritic symptoms in this patient group. LEVEL OF EVIDENCE: Therapeutic, Level 2.

An evaluation of the Herscovici classification for fractures of the medial malleolus.

BACKGROUND: Despite its use in the literature, the application of the Herscovici classification system for medial malleolus fractures has not been evaluated. METHODS: We aimed to determine the reliability and accuracy of the Herscovici classification. The blinded radiographs of 130 patients were independently classified by four orthopaedic trauma surgeons. We held a consensus meeting where observers agreed on a final classification and this served as our reference standard. We used weighted kappa (κ) coefficients of agreement. RESULTS: Twenty-four fractures (18%) were deemed unclassifiable. The classification system demonstrated moderate inter-observer reliability (κ=0.54, 95% CI 0.40-0.68) but substantial reproducibility (κ=0.64, 95% CI 0.51-0.79). Accuracy, when compared with the reference standard, was κ=0.54 (95% CI 0.40-0.66). CONCLUSIONS: The obliquity of the fracture line, and fracture extension, created difficulty in classification in 26% of cases. 18% of our cases could not be classified by majority decision. Our results emphasise the challenges faced in classifying these fractures. Future work should focus on refining the Herscovici classification.

Outcomes after orthopedic trauma.

BACKGROUND: Clinical orthopedic research needs better ability to assess patient expectations with regard to orthopedic trauma surgery outcomes. The aim of this study was to investigate to which extent patient expectations prior to surgery could be met after surgery. METHODS: Patients (≥18 years) with surgical ankle fractures were prospectively recruited at 5 orthopedic trauma clinics in the United States (USA), Canada, and Brazil and followed up for 12 months. Patients were asked to complete a previously validated trauma expectation factor (TEF) questionnaire prior to surgery and a trauma outcome measure (TOM) 1 year after surgery. RESULTS: At 1 year, 155 patients had provided complete records. Almost half (49%; 76/155) had a 1-year TOM score equaling or exceeding their preoperative TEF score (95% CI: 41-57%). The remaining scores failed to meet patient expectations. TOM scores matched or exceeded patient expectations for 33% of patients in the USA and 47% in Canada, but for 69% in Brazil ( p = 0.001 (USA); p = 0.024 (Canada)). This geographical effect was attributable to higher patient expectations in North America as compared to Brazil (average TEF scores: 36 (North America) versus 31 (Brazil); p < 0.001). Patients with lower household income or smokers were more likely to be satisfied with their treatment ( p = 0.02 and p = 0.05, respectively). Furthermore, patients with severe type C fractures had better rates of satisfaction (62%) than patients with simpler B (50%) or type A fractures (33%) ( p = 0.01 [C type versus A type]). CONCLUSIONS: Orthopedic surgeons have difficulty in meeting or exceeding presurgical patient expectations of long-term outcomes for ankle fracture surgery. This study provides evidence that culture, geography, and surgeon-patient communication have considerable influence on patient expectations.

Does it really spin? Intra-medullary nailing of segmental tibial fractures--a cadaveric study.

This study aims to quantify the effect of intra-medullary reaming on rotational displacement of both long diaphyseal segmental tibial fractures (Melis Type III) and short (Melis Type IV) in a cadaveric model with differing degrees of soft tissue stripping. Eighteen fresh-frozen cadaveric specimens (9 matched pairs), median age at death was 85 years (68-92) were used to perform a standardized reaming procedure for an intra-medullary tibial nail and the rotational displacement of the segmental fracture fragment (long and short diaphyseal fractures) was recorded. Rotational displacement was recorded using a goniometer and K-wires positioned in the proximal, segmental and distal fracture fragments. Type III fractures rotate more than Type IV fractures (p<0.0001). In Type III fractures reaming to fit with 0%, 50% and 100% soft tissue stripping resulted in rotational displacement of 11.7 SD 12), 13 (SD 16.5) and 307.3 (SD 118.1) degrees respectively. In Type IV fractures reaming to fit with 0%, 50% and 100% soft tissue stripping resulted in rotational displacement of 8.5 (SD 5.5), 12.7 (SD 9.9) and 135.3 (SD 147.1) degrees respectively. The use of a pointed reduction clamp or unicortical plate eliminated rotational displacement. Reaming is a major risk factor for rotational displacement of segmental tibial fractures irrespective of the degree of soft tissue stripping. Long diaphyseal segmental fractures rotate more than shorter segmental fractures. We recommend always clamping the fracture during reaming to avoid rotational displacement.

Orthopedic surgeon perspectives on appropriate referral of trauma patients to physical therapy (PT).

OBJECTIVES: To evaluate orthopedic surgeon referral of trauma patients to PT. DESIGN: Cross-sectional survey. SETTING: Alberta, Canada. PARTICIPANTS: Orthopedic surgeons and residents. METHODS: A web-based survey was utilized to poll orthopedic surgeons and residents on referral practices. Statistical analysis using Kruskal-Wallis One-Way Analysis of Variance by Ranks; Post hoc analysis using the minimum significant difference method for multiple comparisons and nonparametric correlations using Spearman's rho. RESULTS: The overall response rate was 48 %. Key indications for referral were range of motion deficits, failure to progress, strength and gait training. Of those surveyed, 72.5 and 26.1 % felt that there was either moderate or significant improvement following PT, respectively. Years in practice had a significant effect on survey responses. Residents and surgeons in practice for >20 years viewed PT as being less important in orthopedic trauma (p < 0.05) and were less likely to refer orthopedic trauma patients to PT (p < 0.05). Residents were less likely to view PT in orthopedic trauma as evidence-based (0.05) and more likely to disagree with the statement that formalized PT results in better outcomes than a prescribed home exercise program (p < 0.05). CONCLUSIONS: There are potential differences in the referral practices of orthopedists of varying levels of experience. Although outcome is viewed as positive following PT, it appears that many orthopedists view a prescribed home exercise program as an acceptable equivalent to formalized PT in the setting of orthopedic trauma. Future research should be directed at determining indicators for formalized PT.

Locked plate fixation of the comminuted distal fibula: a biomechanical study.

BACKGROUND: The purpose of this study was to compare the biomechanical properties of locked versus nonlocked lateral fibular bridge plating of comminuted, unstable ankle fractures in a mode of catastrophic failure. METHODS: We created comminuted Weber C fractures in 8 paired limbs from fresh cadavers. Fractures were plated with either standard or locked one-third tubular bridge plating techniques. Specimens were biomechanically evaluated by external rotation to failure while subjected to a compressive load approximating body weight. We measured the angle to failure, torque to failure, energy to failure and construct stiffness. RESULTS: There was no significant difference in construct stiffness or other biomechanical properties between locked and standard one-third tubular plating techniques. CONCLUSION: We found no difference in biomechanical properties between locked and standard bridge plating of a comminuted Weber C fibular fracture in a model of catastrophic failure. It is likely that augmentation of fixation with K-wires or transtibial screws provides a construct superior to locked bridge plating alone. Further biomechanical and clinical analysis is required to improve understanding of the role of locked plating in ankle fractures and in osteoporotic bone.

TEFTOM: A Promising General Trauma Expectation/Outcome Measure-Results of a Validation Study on Pan-American Ankle and Distal Tibia Trauma Patients.

Background. In orthopedics, there is no instrument specifically designed to assess patients' expectations of their final surgery outcome in general trauma populations. We developed the Trauma Expectation Factor Trauma Outcome Measure (TEFTOM) to investigate the fulfilment of patients' expectations one year after surgery as a measure of general trauma surgical outcomes. The aim of this paper was to assess the psychometric characteristics of this new general trauma outcome measure. Methods. The questionnaire was tested in 201 ankle and distal tibia fracture patients scheduled for surgery. Patients were followed up for twelve months. The TEFTOM questionnaire was evaluated for its criterion validity, internal consistency, reproducibility, and responsiveness. Results. TOM showed good criterion validity against the American Academy of Orthopaedic Surgeons Foot and Ankle Scale (Pearson's correlation coefficient = 0.69-0.77). Internal consistency was acceptable for TEF (Cronbach's alpha = 0.65-0.76) and excellent for TOM (Cronbach's alpha = 0.76-0.85). Reproducibility was moderate to very good (intraclass coefficient correlation (ICC) ≥0.67) for TEF and very good (ICC ≥0.92) for TOM. TOM also proved to be responsive to changes in patients' condition over time (Wald test; P < 0.001). Conclusions. TEFTOM is a promising tool for measuring general trauma outcomes in terms of patients' expectation fulfilment that proved to be valid, internally consistent, reproducible, and responsive to change.

A prospective randomized controlled trial of a bioresorbable calcium phosphate paste (alpha-BSM) in treatment of displaced intra-articular calcaneal fractures.

BACKGROUND: Displaced intra-articular calcaneal fractures are devastating injuries and pose a therapeutic challenge. The purpose of this study was to determine whether open reduction internal fixation (ORIF) plus an injectable bioresorbable calcium phosphate paste (alpha-BSM [bone substitute material]) is superior to ORIF alone in the treatment of calcaneal bone voids encountered after operative treatment of displaced intra-articular calcaneal fractures. METHODS: We prospectively randomized 47 patients with 52 closed displaced intra-articular fractures necessitating operative fixation to receive ORIF alone (n = 28) or ORIF plus alpha-BSM (n = 24). The maintenance of Böhler's angle was evaluated at follow-up visits for more than 1 year. Secondary outcome measures included the SF-36 and lower extremity measure every 6 months, and the Oral Analog Scale (OAS) score at 2 years. RESULTS: There was no difference between the groups in the degree of collapse of Böhler's angle at 6 weeks and 3 months when compared with initial postoperative values. However, at 6 months, the mean collapse of the alpha-BSM and ORIF group was 5.6 degree (SD, 4.5 degree) and ORIF alone was 9.1 degree (SD, 5.8 degree), which was statistically significant (p = 0.03). Final radiographic evaluation after 1 year revealed a Böhler's angle loss of 6.2 degree (SD 5.9 degree) and 10.4 degree (SD 7.1 degree) in alpha-BSM and ORIF and ORIF alone groups, respectively, (p = 0.05). There was no difference between the two groups in regards to secondary outcome measures of general health, limb specific function, and pain past 2 years. CONCLUSION: These results support the use of an injectable, in situ hardening calcium phosphate paste to fill the bone void after a displaced intra-articular calcaneal fracture. There was no impact on general health, limb specific function, and pain past 2 years and no associated complications with alpha-BSM use, supporting it safety as an augment to ORIF.

Complications when using threaded K-wire fixation for displaced intra-articular calcaneal fractures.

A retrospective chart review was performed on patients treated at a level one trauma centre for displaced intra-articular calcaneal fractures by a single trauma surgeon between January 1998 and July 2007. Patients were treated with open reduction and internal fixation utilising the extended lateral incision and a new type of fixation not described before. Threaded 1.575 mm (0.062 in.) Kirschner wires (K-wires) were used for fixation post-operatively along with standard plates, screws and bone substitute. There were 278 fractures in 246 patients that were treated with ORIF for displaced intra-articular calcaneal fractures during this 9-year period. Standard calcaneal lateral approach and hardware was supplemented with percutaneous threaded K-wires. An average of 5.0 fully threaded 1.575 mm K-wires were inserted per calcaneal fracture. Five (1.8%) patients had a K-wire infection; 0.6% of all K-wires became infected and 3.1% of K-wires broke. Lateral calcaneal apical wound issues are minimised and patients experience an overall low complication rate. The fixation also ensures non-weightbearing compliance.

The outcome of displaced intra-articular calcaneal fractures that involve the calcaneocuboid joint.

INTRODUCTION: The outcome of displaced intra-articular fractures of the calcaneus is affected by many factors such as fracture type and age. The restoration and maintenance of the posterior facet is a priority and has a strong correlation with improved outcome. The fracture occasionally extends anteriorly to the calcaneocuboid joint (CCJ). Currently there is little literature discussing pain, functional or radiographic information about calcaneal fractures, which involve the CCJ or those that do not. The aim of this study was to compare pain and functional outcome measurements in a cohort of calcaneal fractures treated operatively and non-operatively to determine whether CCJ involvement was important. PATIENTS AND METHODS: A prospective database of calcaneal fractures managed by a single surgeon was reviewed. CT images allowed us to assess the degree of CCJ involvement before and after surgery. Final outcome was determined by pain (validated visual analogue score) and functional outcomes (SF-36) taken 2 years after injury with further CT imaging used to determine the presence of arthritic change at the CCJ. 59 patients with 64 intra-articular calcaneal fractures were identified who also had 35 fractures that extended to the CCJ. Pre-operative CT imaging identified 3 levels of CCJ involvement: Undisplaced fracture line (n=27); fractures that involved <50% of the CCJ (n=4) and fractures that involved >50% of the CCJ with joint subluxation (n=4). RESULTS: Pain and functional scores were comparable between fractures that involved the CCJ and those that did not. All fractures that involved >50% of the CCJ demonstrated arthritic change 2-years after injury. DISCUSSION: Displaced intra-articular fractures of the calcaneus will often have a fracture line extending into the CCJ. This is commonly undisplaced and does not appear to predict continued pain, dysfunction on radiographic appearance using generalised outcome measurements.

Hardware removal after tibial fracture has healed.

BACKGROUND: Tibial fractures are the most common long bone fracture. The standard of care for the treatment of diaphyseal tibial fractures is an intramedullary nail (IMN). Implant removal is one of the most common procedures in bone and joint surgery, and criteria for implant removal are typically left to the treating surgeon. Currently, no clear criteria exist to guide a surgeon's decision to remove implanted tibial IMNs after healing. METHODS: We undertook a retrospective chart review of a single surgeon's practice from January 1996 to February 2005. We identified patients aged 16-70 years with a tibial fracture treated with an IMN. Patients were followed until fracture union and/or request for IMN removal. The following parameters were recorded: reason for implant removal, age, sex, mechanism of fracture, location of fracture, diameter of IMN, Workers' Compensation Board (WCB) status, activity level, litigation status, insurance involvement, height, weight and body mass index (BMI). RESULTS: Factors influencing the likelihood of removal were sex and litigation. Factors not influencing the likelihood of removal were age, weight, height, BMI, diameter of IMN, patients' level of activity, insurance claim involvement and WCB involvement. Overall, 72.2% of patients had an improvement in their symptoms after IMN removal. CONCLUSION: Sex and litigation are positive predictive factors for patient requests to have tibial IMNs removed after healing.

Functional outcome (SF-36) of patients with displaced calcaneal fractures compared to SF-36 normative data.

BACKGROUND: The purpose of this study was to demonstrate the general health status after treatment of displaced intraarticular calcaneal fractures compared to normative data, other orthopaedic procedures, and other medical conditions. METHODS: Three hundred and twelve patients between 25 and 64 years of age were treated for displaced intraarticular calcaneal fractures at a Level I trauma center. Followup ranged from 2 to 8 years. The Short Form 36 Health Status Survey (SF-36) was used for outcome measurement. RESULTS: The scores in eight SF-36 categories in patients with displaced intraarticular calcaneal fractures differed by more than five points from the population norms. This suggests that there is clinical and social relevance to this injury. Outcomes in patients with displaced intraarticular calcaneal fractures were not as good across most SF-36 categories as were outcomes of patients with other orthopaedic conditions. Outcomes in patients with intraarticular calcaneal fractures also were worse across most categories than outcomes in patients who had organ transplants or myocardial infarctions. CONCLUSION: By comparing treatment for displaced intraarticular calcaneal fractures with treatment for orthopaedic problems or other disease processes, we concluded that intraarticular calcaneal fractures are serious life-changing events.

Displaced intra-articular calcaneal fractures.

Deciding how to manage displaced intra-articular calcaneal fractures is challenging. Preoperative assessment of the fracture, patient status, and the patient's functional needs are important in determining treatment approach. In general, older, sedentary patients and those with no or with minimally displaced fractures may be treated successfully with nonsurgical management. Traits strongly predictive of satisfaction with surgery include age younger than 40 years, simple fracture pattern, and accurate reduction. Smoking, diabetes, and peripheral vascular disease markedly increase the risk of surgical complications. In addition, the quality of surgical reduction affects outcome.