OPerative versus non-opERAtive management of isolated ULNAr diaphyseal fractures (OPERA-Ulna): protocol for a randomized controlled trial.

Aims: Isolated fractures of the ulnar diaphysis are uncommon, occurring at a rate of 0.02 to 0.04 per 1,000 cases. Despite their infrequency, these fractures commonly give rise to complications, such as nonunion, limited forearm pronation and supination, restricted elbow range of motion, radioulnar synostosis, and prolonged pain. Treatment options for this injury remain a topic of debate, with limited research available and no consensus on the optimal approach. Therefore, this trial aims to compare clinical, radiological, and functional outcomes of two treatment methods: open reduction and internal fixation (ORIF) versus nonoperative treatment in patients with isolated ulnar diaphyseal fractures. Methods: This will be a multicentre, open-label, parallel randomized clinical trial (under National Clinical Trial number NCT01123447), accompanied by a parallel prospective cohort group for patients who meet the inclusion criteria, but decline randomization. Eligible patients will be randomized to one of the two treatment groups: 1) nonoperative treatment with closed reduction and below-elbow casting; or 2) surgical treatment with ORIF utilizing a limited contact dynamic compression plate and screw construct. The primary outcome measured will be the Disabilities of the Arm, Shoulder and Hand questionnaire score at 12 months post-injury. Additionally, functional outcomes will be assessed using the 36-Item Short Form Health Survey and pain visual analogue scale, allowing for a comparison of outcomes between groups. Secondary outcome measures will encompass clinical outcomes such as range of motion and grip strength, radiological parameters including time to union, as well as economic outcomes assessed from enrolment to 12 months post-injury. Ethics and dissemination: This trial has been approved by the lead site Conjoint Health Research Ethics Board (CHREB; REB14-2004) and local ethics boards at each participating site. Findings from the trial will be disseminated through presentations at regional, national, and international scientific conferences and public forums. The primary results and secondary findings will be submitted for peer-reviewed publication.

Preclinical models of orthopaedic trauma: Orthopaedic Research Society (ORS) and Orthopaedic Trauma Association (OTA) symposium 2022.

Orthopaedic trauma remains a leading cause of patient morbidity, mortality, and global health care burden. Although significant advances have been made in the diagnosis, treatment, and rehabilitation of these injuries, complications such as malunion, nonunion, infection, disuse muscle atrophy and osteopenia, and incomplete return to baseline function still occur. The significant inherent clinical variability in fracture care such as differing patient demographics, injury patterns, and treatment protocols make standardized and replicable study, especially of cellular and molecular based mechanisms, nearly impossible. Hence, the scientists dedicated to improving therapy and treatments for patients with orthopaedic trauma rely on preclinical models. Preclinical models have proven to be invaluable in understanding the timing between implant insertion and bacterial inoculation on the bioburden of infection. Posttraumatic arthritis (PTOA) can take years to develop clinically, but with a porcine pilon fracture model, posttraumatic arthritis can be reliably induced, so different surgical and therapeutic strategies can be tested in prevention. Conversely, the racehorse presents a well-accepted model of naturally occurring PTOA. With preclinical polytrauma models focusing on chest injury, abdominal injury, multiple fractures, and/or head injury, one can study how various injury patterns affect fracture healing can be systemically studied. Finally, these preclinical models serve as a translational bridge to for clinical application in human patients. With selection of the right preclinical model, studies can build a platform to decrease the risk of emerging technologies and provide foundational support for therapeutic clinical trials. In summary, orthopaedic trauma preclinical models allow scientists to simplify a complex clinical challenge, to understand the basic pathways starting with lower vertebrate models. Then, R&D efforts progress to higher vertebrate models to build in more complexity for translation of findings to the clinical practice.

Effectiveness of Thromboprophylaxis Agents Following Hip Fracture: A Systematic Review and Network Meta-Analysis.

Background: Multiple studies have compared different pharmacologic thromboprophylaxis agents after hip fracture surgery, including aspirin, unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), direct oral anticoagulants (DOAC), and warfarin, resulting in variability in clinical practice. To guide clinical management, a systematic review and network meta-analysis (NMA), which enables the simultaneous assessment of the effects of multiple interventions for the same patient population, was performed. This study aimed to determine the comparative effectiveness of thromboprophylaxis in reducing venous thromboembolism (VTE) in patients with surgically treated hip fractures. Methods: The primary outcome was the effect of the treatment on the VTE rate, and the secondary outcome was the treatment effect on the bleeding rate. Relevant studies were identified by a systematic search of Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from January 2000 to February 2022. Title, abstract, and full-text screening; data extraction; and risk-of-bias assessment were performed. All studies examining thromboprophylaxis interventions (DOAC, LMWH, UFH, aspirin, and warfarin) in patients with a surgically treated hip fracture were included. Bayesian NMA was performed, and dichotomous outcome data were pooled using the odds ratio. Interventions were ranked using the surface under the cumulative ranking curve (SUCRA) for each outcome. Results: A total of 19 studies were included after the screening of 466 citations and 77 full-text articles. Of the included studies, 15 studies had a high overall risk of bias. The NMA of the VTE outcome included 19 studies, 49,409 participants, and 6 thromboprophylaxis interventions. The NMA of the bleeding outcome included 3 studies, 18,163 participants, and 3 interventions. The mean age ranged from 43.5 to 86.2 years among the included studies. No thromboprophylaxis intervention was statistically different from any other intervention in its effect on the VTE or bleeding rate in hip fracture patients. Conclusions: This NMA demonstrated that there was no difference between the thromboprophylaxis interventions in reducing VTE or bleeding rates in hip fracture patients. More robust randomized controlled trials are needed to determine the most effective thromboprophylaxis interventions for patients with hip fractures. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Postfasciotomy Classification System for Acute Compartment Syndrome of the Leg.

OBJECTIVE: Acute compartment syndrome (ACS) is a true emergency. Even with urgent fasciotomy, there is often muscle damage and need for further surgery. Although ACS is not uncommon, no validated classification system exists to aid in efficient and clear communication. The aim of this study was to establish and validate a classification system for the consequences of ACS treated with fasciotomy. METHODS: Using a modified Delphi method, an international panel of ACS experts was assembled to establish a grading scheme for the disease and then validate the classification system. The goal was to articulate discrete grades of ACS related to fasciotomy findings and associated costs. A pilot analysis was used to determine questions that were clear to the respondents. Discussion of this analysis resulted in another round of cases used for 24 other raters. The 24 individuals implemented the classification system 2 separate times to compare outcomes for 32 clinical cases. The accuracy and reproducibility of the classification system were subsequently calculated based on the providers' responses. RESULTS: The Fleiss Kappa of all raters was at 0.711, showing a strong agreement between the 24 raters. Secondary validation was performed for paired 276 raters and correlation was tested using the Kendall coefficient. The median correlation coefficient was 0.855. All 276 pairs had statistically significant correlation. Correlation coefficient between the first and second rating sessions was strong with the median pair scoring at 0.867. All surgeons had statistically significant internal consistency. CONCLUSION: This new ACS classification system may be applied to better understand the impact of ACS on patient outcomes and economic costs for leg ACS.

Post hip fracture orthogeriatric care-a Canadian position paper addressing challenges in care and strategies to meet quality indicators.

INTRODUCTION: Osteoporosis is a major disease state associated with significant morbidity, mortality, and health care costs. Less than half of the individuals sustaining a low energy hip fracture are diagnosed and treated for the underlying osteoporosis. OBJECTIVE: A multidisciplinary Canadian hip fracture working group has developed practical recommendations to meet Canadian quality indicators in post hip fracture care. METHODS: A comprehensive narrative review was conducted to identify and synthesize key articles on post hip fracture orthogeriatric care for each of the individual sections and develop recommendations. These recommendations are based on the best evidence available today. CONCLUSION: Recommendations are anticipated to reduce recurrent fractures, improve mobility and healthcare outcomes post hip fracture, and reduce healthcare costs. Key messages to enhance postoperative care are also provided.

Safety of expedited-surgery protocols in anticoagulant-treated patients with hip fracture: a systematic review and meta-analysis.

BACKGROUND: Perioperative management of patients with hip fracture patients receiving oral anticoagulants requires navigating the risks associated with surgical delay and perioperative hemostasis. The aim of this systematic review and meta-analysis was to evaluate the effect of expedited-surgery protocols on time to surgery and perioperative outcomes in anticoagulant-treated patients with hip fracture. METHODS: We searched MEDLINE, Embase and CENTRAL from inception to May 5, 2020, to identify English-language studies reporting outcomes after expedited hip fracture surgery in patients receiving vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) before hospital admission. We performed a meta-analysis using Mantel-Haenszel weighting for dichotomous variables and inverse variance weighting for continuous variables. RESULTS: Among the 4253 citations identified, 14 studies were included. In the 6 studies eligible for meta-analysis, compared to hip fracture surgery before implementation of a VKA-reversal protocol, surgery after implementation of such a protocol was associated with a significant reduction in time to surgery (mean difference 45.31 h, 95% confidence interval [CI] 15.81 h to 74.80 h). Expedited surgery (within 48 h) in patients who received DOACs preoperatively was not associated with increased surgical duration (mean difference -7.29 min, 95% CI -22.5 min to 7.95 min) or 30-day mortality (odds ratio [OR] 1.30, 95% CI 0.49 to 3.89) compared to patients who did not receive anticoagulants (control patients). However, expedited surgery in DOAC-treated patients was associated with an increased blood transfusion risk compared to control patients (OR 0.58, 95% CI 0.36 to 0.96). CONCLUSION: Implementing a VKA-reversal protocol for patients with hip fracture is effective in decreasing time to surgery, without an increased bleeding risk. Performing hip fracture surgery within 48 hours in DOAC-treated patients is also safe, with a small increase in blood transfusion risk.

Overexpression of facilitative glucose transporter-3 and membrane procoagulation in maternal platelets of preeclamptic pregnancy.

BACKGROUND: Preeclampsia (PE) is a hypertensive disorder during pregnancy that results in significant adverse maternal and neonatal outcomes. Platelet activation is present in PE and contributes to the thrombo-hemorrhagic states of the disorder. However, the mechanisms that initiate and/or sustain platelet activation in PE are ill-defined. OBJECTIVES: We aimed to characterise this mechanism and the procoagulant potentials of platelets in PE. METHODS: In this quantitative observational study, we analyzed platelet procoagulant membrane dynamics in patients with PE (n = 21) compared with age-matched normotensive pregnancies (n = 20), gestational hypertension (n = 10), and non-pregnant female controls (n = 19). We analyzed fluorescently labeled indicators of platelet activation, bioenergetics, and procoagulation (phosphatidylserine exposure and thrombin generation), coupled with high-resolution imaging and thrombelastography. We then validated our findings using flow cytometry, immunoassays, classical pharmacology, and convolutional neural network analysis. RESULTS: PE platelets showed significant ultra-structural remodeling, are more extensively preactivated than in healthy pregnancies and can circulate as microaggregates. Preactivated platelets of PE externalized phosphatidylserine and thrombin formed on the platelet membranes. Platelets' expression of facilitative glucose transporter-1 increased in all pregnant groups. However, PE platelets additionally overexpress glucose transporter-3 to enhance glucose uptake and sustain activation and secretion events. Although preeclampsia platelets exposed to subendothelial collagen showed incremental activation, the absolute hemostatic response to collagen was diminished, and likely contributed to greater blood loss perioperatively. CONCLUSIONS: We revealed 2 bioenergetic mediators in the mechanism of sustained platelet procoagulation in preeclampsia. Although glucose transporter-1 and glucose transporter-3 remain elusive antiprocoagulant targets, they may be sensitive monitors of PE onset and progression.

What Are the Challenges Related to Family Planning, Pregnancy, and Parenthood Faced by Women in Orthopaedic Surgery? A Systematic Review.

BACKGROUND: Orthopaedic surgery is the surgical specialty with the lowest proportion of women. Conflicting evidence regarding the potential challenges of pregnancy and parenthood in orthopaedics, such as the implications of delayed childbearing, may be a barrier to recruitment and retainment of women in orthopaedic surgery. A summary of studies is needed to ensure that women who have or wish to have children during their career in orthopaedic surgery are equipped with the relevant information to make informed decisions. QUESTIONS/PURPOSES: In this systematic review, we asked: What are the key gender-related barriers pertaining to (1) family planning, (2) pregnancy, and (3) parenthood that women in orthopaedic surgery face? METHODS: Embase, MEDLINE, and PsychINFO were searched on June 7, 2021, for studies related to pregnancy or parenthood as a woman in orthopaedic surgery. Inclusion criteria were studies in the English language and studies describing the perceptions or experiences of attending surgeons, trainees, or program directors. Studies that sampled surgical populations without specific reference to orthopaedics were excluded. Quantitative and qualitative analyses were performed to identify important themes. Seventeen articles including surveys (13 studies), selective reviews (three studies), and an environmental scan (one study) met the inclusion criteria. The population sampled included 1691 attending surgeons, 864 trainees, and 391 program directors in the United States and United Kingdom. The Risk of Bias Instrument for Cross-Sectional Surveys of Attitudes and Practices tool was used to evaluate the risk of bias in survey studies. A total of 2502 women and 560 men were sampled in 13 surveys addressing various topics related to pregnancy, parenthood, and family planning during an orthopaedic career. Three selective reviews provided information on occupational hazards in the orthopaedic work environment during pregnancy, while one environmental scan outlined the accessibility of parental leave policies at 160 residency programs. Many of the survey studies did not report formal clarity, validity, or reliability assessments, therefore increasing their risk of bias. However, our analysis of the provided instruments as well as the consistency of identified themes across multiple survey studies suggests the evidence we aggregated was sufficiently robust to answer the research questions posed in the current systematic review. RESULTS: These data revealed that many women have witnessed or experienced discrimination related to pregnancy and parenthood, at times resulting in a decision to delay family planning. In one study, childbearing was reportedly delayed by 67% of respondents (304 of 452) because of their career choice in orthopaedics. Orthopaedic surgeons were more likely to experience pregnancy complications (range 24% to 31%) than the national mean in the United States (range 13% to 17%). Lastly, despite these challenging conditions, there was often limited support for women who had or wished to start a family during their orthopaedic surgery career. Maternity and parental leave policies varied across training institutions, and only 55% (56 of 102) of training programs in the United States offered parental leave beyond standard vacation time. CONCLUSION: The potential negative effects of these challenges on the orthopaedic gender gap can be mitigated by increasing the availability and accessibility of information related to family planning, parental leave, and return to clinical duties while working as a woman in orthopaedic surgery. Future research could seek to provide a more global perspective and specifically explore regional variation in the environment faced by pregnancy or parenting women in orthopaedic surgery. LEVEL OF EVIDENCE: Level III, prognostic study.

Heightened Procoagulation after Post-Operative Thromboprophylaxis Completion in Patients with Metastatic Bone Disease from Primary Colorectal Cancer.

BACKGROUND: Platelets play a role in venous thromboembolism (VTE) and in mediating colorectal cancer (CRC) progression. Still, platelets' role in hypercoagulability after surgical intervention for metastatic bone disease (MBD) is ill-defined. METHODS: In this quantitative observational study, we utilized a high-resolution imaging approach to temporally examine platelet procoagulant membrane dynamics (PMD) in four patients with MBD from primary CRC (CRC/MBD), before and after surgical intervention, over a 6-month period. We coupled this investigation with thrombelastography, quantitative plasma shotgun proteomics, and biochemical analysis. RESULTS: The plasma of CRC/MBD patients was enriched in ADAM1a, ADAMTS7, and physiological ligands for platelet glycoprotein-VI/spleen tyrosine kinase (GPVI/Syk) activation. Thromboprophylaxis attenuated procoagulation upon its initial prescription (post-operative day one, POD1); however, all patients experienced rebound procoagulation between POD3 and POD14, which was associated with Syk activation (Y525/Y526) in all patients, and a VTE event in two patients. Plasma levels of DNA-histone complexes increased steadily after surgery and remained elevated throughout the study period. Additionally, we increasingly sighted both homotypic and heterotypic platelet microaggregates after surgery in CRC/MBD patients, but not in healthy control participants' plasma. CONCLUSIONS: Our data elucidates the cell biology of a prothrombo-inflammatory state caused by disease and vascular injury, and recalcitrant to thromboprophylaxis. New mechanistic insights into hypercoagulability in CRC/MBD patients may identify novel drug targets for effective thromboprophylaxis type and duration after orthopaedic surgery.

High Rates of Imminent Subsequent Fracture After Femoral Neck Fracture in the Elderly.

BACKGROUND: Fragility fractures of the hip are known to be followed frequently by subsequent fragility fractures, including second hip fractures. Data on subsequent fractures are available for aggregated index femoral neck and intertrochanteric femoral fractures, grouped generically as hip fractures, but not specifically for femoral neck fractures. There is increasing recognition that a subsequent fracture often occurs early after a hip fracture in the elderly, creating an emphasis on the concept of "imminent fracture risk." Since 2000, there have been many reports on the care gap in interventions after a fragility fracture, with concern regarding the slow uptake of appropriate systemic treatments designed to prevent a subsequent fracture in high-risk patients. METHODS: As planned a priori, we performed an analysis of subsequent fractures after an index femoral neck fracture in 2 prospective clinical trials involving 2,520 patients from 90 sites on 5 continents. We recorded the incidence and time of occurrence of all secondary fragility fractures as well as the reported use of bone-protective medication in all subjects. RESULTS: In the 24 months following the index femoral neck fracture, 226 (9.0%) of 2,520 patients sustained at least 1 subsequent fragility fracture, including 113 hip fractures (4.5%). The median interval from the index fracture to a subsequent fracture was approximately 9.0 months. Only 25.2% (634) of the 2,520 patients reported using bone-protective medications at any time during follow-up. Female patients, those with nondisplaced index fractures, and those treated with arthroplasty, were more likely to have received protective medication. CONCLUSIONS: Subsequent fractures, including second hip fractures, occurred frequently and early following an index femoral neck fracture in 2 large global cohorts. Interventions to prevent a subsequent fracture were instituted in only 1 of 4 patients, even though a focused directive was included in both study protocols. LEVEL OF EVIDENCE: Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Hip Fractures in Older Adults Are Associated With the Low Density Bone Phenotype and Heterogeneous Deterioration of Bone Microarchitecture.

Femoral neck areal bone mineral density (FN aBMD) is a key determinant of fracture risk in older adults; however, the majority of individuals who have a hip fracture are not considered osteoporotic according to their FN aBMD. This study uses novel tools to investigate the characteristics of bone microarchitecture that underpin bone fragility. Recent hip fracture patients (n = 108, 77% female) were compared with sex- and age-matched controls (n = 216) using high-resolution peripheral quantitative computed tomography (HR-pQCT) imaging of the distal radius and tibia. Standard morphological analysis of bone microarchitecture, micro-finite element analysis, and recently developed techniques to identify void spaces in bone microarchitecture were performed to evaluate differences between hip fracture patients and controls. In addition, a new approach for phenotyping bone microarchitecture was implemented to evaluate whether hip fractures in males and females occur more often in certain bone phenotypes. Overall, hip fracture patients had notable deterioration of bone microarchitecture and reduced bone mineral density compared with controls, especially at weight-bearing sites (tibia and femoral neck). Hip fracture patients were more likely to have void spaces present at either site and had void spaces that were two to four times larger on average when compared with non-fractured controls (p < 0.01). Finally, bone phenotyping revealed that hip fractures were significantly associated with the low density phenotype (p < 0.01), with the majority of patients classified in this phenotype (69%). However, female and male hip fracture populations were distributed differently across the bone phenotype continuum. These findings highlight how HR-pQCT can provide insight into the underlying mechanisms of bone fragility by using information about bone phenotypes and identification of microarchitectural defects (void spaces). The added information suggests that HR-pQCT can have a beneficial role in assessing the severity of structural deterioration in bone that is associated with osteoporotic hip fractures. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Four-dimensional computed tomography: musculoskeletal applications.

Four-dimensional computed tomography (4DCT), or dynamic CT, is an emerging modality with a wealth of orthopedic applications for both clinical practice and research. This technology creates CT volumes of a moving structure at multiple time points to depict real-time motion. Recent advances in acquisition technology and reduction in radiation dosage have allowed for increased adoption of the modality and have made imaging of joint motion feasible and safe. Musculoskeletal 4DCT has been used primarily to investigate wrist motion; however, the utility of 4DCT has been shown in other areas, including the shoulder, elbow, hip, knee and ankle. Imaging these joints through a full range of motion provides new insight into dynamic phenomena such as instability, impingement and joint kinematics. Although 4DCT has not yet been widely adopted in orthopedic practice and research, future use has the potential to enable a deeper understanding of musculoskeletal conditions and to improve patient care.

In Vivo Syndesmotic Motion After Rigid and Flexible Fixation Using 4-Dimensional Computerized Tomography.

INTRODUCTION: Maintaining reduction after syndesmotic injury is crucial to patient function; however, malreduction remains common. Flexible suture button fixation may allow more physiologic motion of the syndesmosis compared with rigid screw fixation. Conventional syndesmotic imaging fails to account for physiologic syndesmotic motion with ankle range of motion (ROM), providing misleading results. Four-dimensional computerized tomography (4DCT) can image joints through a dynamic ROM. Our purpose was to compare syndesmotic motion after rigid and flexible fixation using 4DCT. METHODS: We analyzed 13 patients with syndesmotic injury who were randomized to receive rigid (n = 7) or flexible (n = 6) fixation. Patients underwent bilateral ankle 4DCT while moving between ankle dorsiflexion and plantar flexion. Measures of syndesmotic position and rotation were extracted from 4DCT to determine syndesmotic motion as a function of ankle ROM. RESULTS: Uninjured ankles demonstrated significant decreases in syndesmotic width of 1.0 mm with ankle plantar flexion (SD = 0.6 mm, P < 0.01). Initial rigid fixation demonstrated reduced motion compared with uninjured ankles in 4 of 5 measures (P < 0.01) despite all patients in the rigid fixation group having removed, loose, or broken screws by the time of imaging. Rigid fixation led to less motion than flexible fixation in 3 measures (P = 0.02-0.04). There were no observed differences in syndesmotic position or motion between flexible fixation and uninjured ankles. CONCLUSION: Despite the loss of fixation in all subjects in the rigid fixation group, initial rigid fixation led to significantly reduced syndesmotic motion. Flexible fixation recreated more physiologic motion compared with rigid fixation and may be used to reduce rates of syndesmotic malreduction. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Biomechanical Evaluation of Different Plate Configurations for Midshaft Clavicle Fracture Fixation: Single Plating Compared with Dual Mini-Fragment Plating.

Background: Dual-plate constructs have become an increasingly common fixation technique for midshaft clavicle fractures and typically involve the use of mini-fragment plates. The goal of this technique is to reduce plate prominence and implant irritation. However, limited biomechanical data exist for these lower-profile constructs. The study aim was to compare dual mini-fragment orthogonal plating with small-fragment clavicle plates for biomechanical noninferiority and to determine if an optimal plate configuration could be identified using a cadaveric model. Methods: Twenty-four cadaveric clavicles were randomized to 1 of 6 groups, stratified by computed tomography-based bone mineral content (BMC): precontoured superior or anterior fixation using a single 3.5-mm Locking Compression Plate (LCP), and 4 different dual-plating constructs utilizing 2.4-mm and 2.7-mm Adaptation plates or LCPs. An inferior butterfly fracture was created. Axial, torsional, and bending (anterior and superior surface loading) stiffnesses were determined through nondestructive cyclic testing, followed by a load-to-failure test in 3-point superior surface bending. Results: For axial stiffness, the 2 dual-plate constructs with a superior 2.4-mm and anterior 2.7-mm plate (either Adaptation or LCP) were significantly stiffer than the other 4 constructs (p = 0.021 and p = 0.034). For both superior and anterior bending, the superior 2.4-mm and anterior 2.7-mm plate constructs were significantly stiffer when compared with the 3.5-mm superior plate (p = 0.043). No significant differences were found in torsional stiffness or load to failure between the different constructs. Conclusions: Dual plating using mini-fragment plates is biomechanically superior for the fixation of midshaft clavicle fractures when compared with a single, superior, 3.5-mm plate and has biomechanical properties similar to those of a 3.5-mm plate placed anteriorly. With the exception of axial stiffness, no significant differences were found when different dual-plating constructs were compared with each other. Clinical Relevance: This study validates the use of dual plating for midshaft clavicle fractures.

An in vivo rabbit joint injury model to measure trauma-induced coagulopathy and the effect of timing of administration of ketotifen fumarate on posttraumatic joint contracture.

Objectives: Using a rabbit in vivo joint injury model, the primary objective of the study was to determine if a relationship exists between earlier time to initiation of ketotifen fumarate (KF) treatment and posttraumatic joint contracture (PTJC) reduction. The secondary objective was to determine if a coagulation response could be detected with serial thrombelastography (TEG) analysis following acute trauma in this model. Methods: PTJC of the knee were created in 25 skeletally mature, New Zealand White rabbits. Five groups of 5 animals were studied: a control group that received twice daily subcutaneous injections of normal saline and 4 treatment groups that received twice daily subcutaneous injections of KF (0.5 mg/kg) starting immediately, 1-, 2-, and 4-weeks post-injury. After 8 weeks of immobilization, flexion contractures were measured biomechanically. Serial TEG analysis was performed on the control group animals pre-injury and weekly post-injury. Results: The average joint contracture in the Control Group (43.1°â€Š±â€Š16.2°) was higher than all KF treatment groups; however, the differences were not statistically significant. The average joint contracture was lowest in the 2-week post-injury treatment group (29.4°â€Š±â€Š12.1°), although not statistically significant compared to the other treatment groups. Serial TEG analysis demonstrated significantly higher mean maximal amplitude (maximal amplitude = 68.9 ±â€Š1.7 mm; P < .001), alpha-angle (81.9°â€Š±â€Š0.9°; P < .001), and coagulation index (4.5 ±â€Š0.3; P < .001) 1-week post-injury, which normalized to pre-injury values by 5-weeks post-injury. Conclusions: The use of the mast cell stabilizer KF within 2 weeks of injury demonstrated a nonsignificant trend towards reducing joint contracture in a rabbit in vivo model of PTJC. TEG and the in vivo rabbit joint injury model may be valuable in future preclinical studies of venous thromboembolism prevention and furthering our understanding of the pathophysiology of posttraumatic hypercoagulability.

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.

Comparison of Patient-Reported Outcomes After Suprapatellar Versus Infrapatellar Nailing Techniques for Tibial Shaft Fractures: A Systematic Review and Meta-analysis.

OBJECTIVES: To compare patient-reported outcome measures (PROMs) between patients who underwent intramedullary nail (IMN) fixation for tibial shaft fractures using an infrapatellar (IP) or the newer suprapatellar (SP) approach. Secondary outcomes included fluoroscopic radiation exposure, operative time, and radiographic outcomes. DATA SOURCES: A systematic literature search of the databases Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials Study Selection. STUDY SELECTION: Level I to III studies in which patients over the age of 18 years with acute tibial shaft fractures who underwent tibial IMN fixation using an IP or SP approach for fracture fixation were assessed for inclusion. Studies with a minimum of 10 patients in each cohort that reported on postoperative patient-reported outcomes with at least 6 months of follow-up were included for analysis. DATA EXTRACTION AND SYNTHESIS: Twelve studies that reported PROMs and compared IP and SP intramedullary nailing of tibial shaft fractures were analyzed. This included 654 patients who underwent IP IMN fixation and 542 patients who underwent SP IMN fixation. A random-effects model for unadjusted/crude study estimates were pooled using inverse variance (IV) weighting for continuous variable analysis. CONCLUSIONS: This review found a significant improvement in PROM for patients with tibial shaft fractures when the SP IMN technique was used. In addition, there was a significant decrease in intraoperative fluoroscopy time consistent with other radiographic findings demonstrating improved start point accuracy and reduction with SP IMN fixation of tibial shaft fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Mortality and cardiovascular events in adults with kidney failure after major non-cardiac surgery: a population-based cohort study.

BACKGROUND: People with kidney failure have a high incidence of major surgery, though the risk of perioperative outcomes at a population-level is unknown. Our objective was to estimate the proportion of people with kidney failure that experience acute myocardial infarction (AMI) or death within 30 days of major non-cardiac surgery, based on surgery type. METHODS: In this retrospective population-based cohort study, we used administrative health data to identify adults from Alberta, Canada with major surgery between April 12,005 and February 282,017 that had preoperative estimated glomerular filtration rates (eGFRs) < 15 mL/min/1.73m2 or received chronic dialysis. The index surgical procedure for each participant was categorized within one of fourteen surgical groupings based on Canadian Classification of Health Interventions (CCI) codes applied to hospitalization administrative datasets. We estimated the proportion of people that had AMI or died within 30 days of the index surgical procedure (with 95% confidence intervals [CIs]) following logistic regression, stratified by surgery type. RESULTS: Overall, 3398 people had a major surgery (1905 hemodialysis; 590 peritoneal dialysis; 903 non-dialysis). Participants were more likely male (61.0%) with a median age of 61.5 years (IQR 50.0-72.7). Within 30 days of surgery, 272 people (8.0%) had an AMI or died. The probability was lowest following ophthalmologic surgery at 1.9% (95%CI: 0.5, 7.3) and kidney transplantation at 2.1% (95%CI: 1.3, 3.2). Several types of surgery were associated with greater than one in ten risk of AMI or death, including retroperitoneal (10.0% [95%CI: 2.5, 32.4]), intra-abdominal (11.7% [8.7, 15.5]), skin and soft tissue (12.1% [7.4, 19.1]), musculoskeletal (MSK) (12.3% [9.9, 15.5]), vascular (12.6% [10.2, 15.4]), anorectal (14.7% [6.3, 30.8]), and neurosurgical procedures (38.1% [20.3, 59.8]). Urgent or emergent procedures had the highest risk, with 12.1% experiencing AMI or death (95%CI: 10.7, 13.6) compared with 2.6% (1.9, 3.5) following elective surgery. CONCLUSIONS: After major non-cardiac surgery, the risk of death or AMI for people with kidney failure varies significantly based on surgery type. This study informs our understanding of surgery type and risk for people with kidney failure. Future research should focus on identifying high risk patients and strategies to reduce these risks.