Wound infection following implant removal of foot, ankle, lower leg or patella; a protocol for a multicenter randomized controlled trial investigating the (cost-)effectiveness of 2 g of prophylactic cefazolin compared to placebo (WIFI-2 trial).

BACKGROUND: Elective implant removal (IR) after fracture fixation is one of the most common procedures within (orthopedic) trauma surgery. The rate of surgical site infections (SSIs) in this procedure is quite high, especially below the level of the knee. Antibiotic prophylaxis is not routinely prescribed, even though it has proved to lower SSI rates in other (orthopedic) trauma surgical procedures. The primary objective is to study the effectiveness of a single intravenous dose of 2 g of cefazolin on SSIs after IR following fixation of foot, ankle and/or lower leg fractures. METHODS: This is a multicenter, double-blind placebo controlled trial with a superiority design, including adult patients undergoing elective implant removal after fixation of a fracture of foot, ankle, lower leg or patella. Exclusion criteria are: an active infection, current antibiotic treatment, or a medical condition contraindicating prophylaxis with cefazolin including allergy. Patients are randomized to receive a single preoperative intravenous dose of either 2 g of cefazolin or a placebo (NaCl). The primary analysis will be an intention-to-treat comparison of the proportion of patients with a SSI at 90 days after IR in both groups. DISCUSSION: If 2 g of prophylactic cefazolin proves to be both effective and cost-effective in preventing SSI, this would have implications for current guidelines. Combined with the high infection rate of IR which previous studies have shown, it would be sufficiently substantiated for guidelines to suggest protocolled use of prophylactic antibiotics in IR of foot, ankle, lower leg or patella. Trial registration Nederlands Trial Register (NTR): NL8284, registered on 9th of January 2020, https://www.trialregister.nl/trial/8284.

Direct Oral Anticoagulants Are a Potential Alternative to Low-Molecular-Weight Heparin for Thromboprophylaxis in Trauma Patients Sustaining Lower Extremity Fractures.

BACKGROUND: Trauma patients are at a significant risk of venous thromboembolism (VTE), with lower extremity fractures (LEF) being independent risk factors. Use of direct oral anticoagusants (DOACs) for VTE prophylaxis is effective in elective orthopedic surgery, but currently not approved for trauma patients. The primary objective of this study was to compare the effectiveness and safety of thromboprophylaxis of DOACs with low-molecular-weight heparin (LMWH) in trauma patients sustaining LEF. MATERIALS AND METHODS: We included adult trauma patients admitted to trauma quality improvement program participating trauma centers (between 2013 and 2016), who sustained LEF and were started on DOACs or LMWH for thromboprophylaxis after admission. Propensity score matching was performed to compare symptomatic VTE and bleeding control interventions between the groups. RESULTS: Of 1,009,922 patients in trauma quality improvement program, 167,640 met inclusion criteria (165,009 received LMWH and 2631 received DOACs). After propensity score matching, 2280 predominantly elderly (median age: 67 y) isolated femur fracture patients (median ISS: 10) were included in each group (4560 patients in total). Symptomatic VTE occurred in 1.4% of patients in both matched groups (P = 0.992). Bleeding control interventions occurred less often in the DOAC group, albeit statistically insignificant (5.8% versus 6.0%, P = 0.772). CONCLUSIONS: This study found similar rates of VTE and bleeding control measures for thromboprophylaxis with DOACs or LMWH in matched trauma patients with LEF. Further prospective research is warranted to consolidate the safety of DOAC thromboprophylaxis in trauma patients with LEF. Favorable oral administration and likely increased adherence could benefit this high-risk population.

Expanding the horizons of clinical applications of proximal humerus locking plates in the lower extremities: A technical note.

Pre-contoured anatomical locking plates were designed to address the clinical need of fixing small epiphyseal segments with a larger number of screws. Those plates match the contour and shape of a variety of bones allowing for optimal buttress properties. The aim of this manuscript is to highlight the benefits of applying proximal humerus locking plates in the fixation of lower extremity bones. Although designed for the proximal humerus, the low-profile plate shape and anatomic contour also provides versatile use in certain areas of the lower extremity. This technical narrative highlights the versatile and reliable use of this plate for other anatomical areas than the one to which it has been originally conceived.

Perioperative symptomatic venous thromboembolism after immediate chemoprophylaxis in patients with pelvic and lower-extremity fractures.

The purpose of this study was to investigate the incidence of symptomatic venous thromboembolism (VTE) after chemoprophylaxis in patients with pelvic and lower-extremity fractures, and to identify risk factors for VTEs in this subgroup of patients. To detect VTE, multi-detector computed tomography (CT) angiography was performed. Of 363 patients assessed, the incidence of symptomatic VTE was 12.4% (45 patients), and the incidence of symptomatic PE was 5.2% (19 patients). For the risk-factor analysis, a higher Charlson comorbidity index (p = 0.037), and a history of external fixator application (p = 0.007) were associated with increased VTE risk. Among patients who had VTE, male sex (p = 0.017), and above-the-knee fractures (p = 0.035) were associated with increased pulmonary embolism (PE) risk. In conclusions, the incidence of VTE in post-traumatic patients is not low after chemoprophylaxis. Risk factors for VTE and PE are different among patients with pelvic and lower-extremity fractures.

Cost-effectiveness of negative-pressure wound therapy in adults with severe open fractures of the lower limb: evidence from the WOLLF randomized controlled trial.

AIMS: The aim of this study was to estimate the cost-effectiveness of negative-pressure wound therapy (NPWT) in comparison with standard wound management after initial surgical wound debridement in adults with severe open fractures of the lower limb. PATIENTS AND METHODS: An economic evaluation was conducted from the perspective of the United Kingdom NHS and Personal Social Services, based on evidence from the 460 participants in the Wound Management of Open Lower Limb Fractures (WOLLF) trial. Economic outcomes were collected prospectively over the 12-month follow-up period using trial case report forms and participant-completed questionnaires. Bivariate regression of costs (given in £, 2014 to 2015 prices) and quality-adjusted life-years (QALYs), with multiple imputation of missing data, was conducted to estimate the incremental cost per QALY gained associated with NPWT dressings. Sensitivity and subgroup analyses were undertaken to assess the impacts of uncertainty and heterogeneity, respectively, surrounding aspects of the economic evaluation. RESULTS: The base case analysis produced an incremental cost-effectiveness ratio of £267 910 per QALY gained, reflecting higher costs on average (£678; 95% confidence interval (CI) -£1082 to £2438) and only marginally higher QALYS (0.002; 95% CI -0.054 to 0.059) in the NPWT group. The probability that NPWT is cost-effective in this patient population did not exceed 27% regardless of the value of the cost-effectiveness threshold. This result remained robust to several sensitivity and subgroup analyses. CONCLUSION: This trial-based economic evaluation suggests that NPWT is unlikely to be a cost-effective strategy for improving outcomes in adult patients with severe open fractures of the lower limb. Cite this article: Bone Joint J 2019;101-B:1392-1401.

Patient experience of long-term recovery after open fracture of the lower limb: a qualitative study using interviews in a community setting.

OBJECTIVES: Treatment of open fractures is complex and patients may require muscle and skin grafts. The aim of this study was to gain a greater understanding of patient experience of recovery from open fracture of the lower limb 2-4 years postinjury. DESIGN: A phenomenological approach was used to guide the design of the study. Interviews took place between October 2016 and April 2017 in the participants' own homes or via telephone. SETTING: England, UK. PARTICIPANTS: A purposive sample of 25 patients were interviewed with an age range of 26-80 years (median 51), 19 were male and six female, and time since injury was 24-49 months (median 35 months). RESULTS: The findings identified a focus on struggling to recover as participants created a new way of living, balancing moving forward with accepting how they are, while being uncertain of the future and experiencing cycles of progress and setbacks. This was expressed through three themes: (i) 'being disempowered' with the emotional impact of dependency and uncertainty, (ii) 'being changed' and living with being fragile and being unable to move freely and (iii) 'being myself' with a loss of self, feeling and looking different, alongside recreation of self in which they integrated the past, present and future to find meaningful ways of being themselves. CONCLUSION: This study identified the long-term disruption caused by serious injury, the hidden work of integration that is required in order to move forward and maximise potential for recovery. Supportive strategies that help people to self-manage their everyday emotional and physical experience of recovery from injury are required. Research should focus on developing and testing effective interventions that provide support and self-management within a holistic rehabilitation plan. TRIAL REGISTRATION NUMBER: Current Controlled Trials ISRCTN33756652; Post-results.

[Long bone fractures in cattle: A retrospective study of treatment and outcome in 194 cases]. / Frakturen der langen Röhrenknochen beim Rind: Eine retrospektive ­Auswertung der Therapie und des Verlaufs bei 194 Tieren.

INTRODUCTION: The present retrospective study investigated the localization, cause, treatment and healing of long bone fractures in cattle. Over a period of ten years, medical records of 194 cattle of all ages with a long bone fracture, presented at the Clinic for Ruminants with Ambulatory and Herd Health Services at LMU Munich, were evaluated. The majority of patients (n = 131, 67.5%) were younger than two weeks of age. Of these, 118 calves sustained the fracture on the day of birth (60.8%). An obstetrical assistance was found in 57.4% (n = 58) of birth-related cases as a fracture cause. The femur was most frequently affected in calves aged up to two weeks (n = 35; 26.7%). The second most frequent fractures occurred in the metacarpus (n = 31; 22.9%) in this age group, followed by metatarsus (n = 28; 21.4%) and tibia (n = 27; 20.6%). Fractures of the antebrachium (n = 9; 6.9%) and the humerus were rare (n = 1; 0.8%). A total of 194 patients were diagnosed with 50 femur fractures (25.8%), 53 metacarpal fractures (27.3%), 43 metatarsal fractures (22.2%), 30 tibial fractures (15.5%), 11 antebrachial fractures (5.7%) and 7 humeral fractures (3.6%). Of the 194 animals, 78 (40.2%) had to be euthanized, 42 of them (53.8%) without treatment. In 150 patients, treatment was initiated, of which 110 patients (73.3%) were dismissed healthy from the clinic. Among the conservative treatment methods were stall rest, casts, casts combined with a U-shaped metal rail (walking casts) and the Thomas splint. Surgical therapy (internal fixation with plates or screws, transfixation pin casts) was used to treat 65 animals (33.5%). While 86.9% (74 out of 85) of the conservatively treated animals left the clinic alive, it were only 58.1% (36 out of 65) animals after surgical treatment. In the newborn calves, colostrum supply had a significant effect on the success of the treatment. If the gamma-glutamyl transferase concentration was below 200 IU/L in the calves aged under 4 days, the healing rate was significantly different from the cure rate of sufficiently immunized patients (26.9% (7 out of 26) vs. 65.3% (47 out of 72), P = 0.001).

INTRODUCTION: La présente étude rétrospective a examiné la localisation, la cause, le traitement et la guérison des fractures des os longs chez les bovins. Sur une période de dix ans, les dossiers médicaux de 194 bovins de tous âges souffrant d'une fracture d'un os long et présentés à la Clinique pour les ruminants avec services ambulatoires et services de santé du troupeau à la Ludwig-Maximilians-Universität de Munich, ont été évalués. La majorité des patients (n = 131, 67,5%) étaient âgés de moins de deux semaines. Parmi ceux-ci, 118 veaux ont subi la fracture le jour de leur naissance (60,8%). Une assistance obstétricale par traction a été trouvée dans 57,4% (n = 58) des cas liés à la naissance en tant que cause de fracture. Le fémur était le plus souvent touché chez les veaux âgés de moins de deux semaines (n = 35; 26,7%).). La deuxième fracture la plus fréquente survenait au niveau du métacarpe (n = 31; 22,9%)), suivi du métatarse (n = 28; 21,4%) et du tibia (n = 27; 20,6%).). Les fractures de l'antebrachium (n = 9; 6,9%) et de l'humérus étaient rares (n = 1; 0,8%). Au total, sur les 194 patients ont a diagnostiqué 50 fractures du fémur (25,8%), 53 fractures du métacarpe (27,3%), 43 fractures du métatarse (22,2%), 30 fractures du tibia (15,5%), 11 fractures antébrachiales (5,7%) et 7 fractures de l'humérus (3,6%). Sur les 194 animaux, 78 (40,2%) ont dû être euthanasiés, dont 42 (53,8%) sans traitement. Deux animaux (1.0%) ont été abattus. Sur les 150 patients traités, 36 (24.0%) ont été euthanasiés et 4 ont péri. 110 patients (73,3%) ont été renvoyés en bonne santé de la clinique. Parmi les méthodes de traitement conservatif figurent le repos en stalle, les plâtres en résine, les plâtres en résine combinés à une attelle en métal en forme de U comme attelle de marche et l'attelle de Thomas. Un traitement chirurgical (fixation interne à l'aide de plaques et/ou de vis de traction, broches de transfixion avec pont en matière synthétique) a été utilisé pour traiter 65 animaux (33,5%). Alors que 86,9% (74 sur 85) des animaux traités de manière conservatrice ont quitté la clinique en vie, ce ne sont que 58,1% (36 sur 65) des animaux après traitement chirurgical. Chez les veaux nouveau-nés, l'apport de colostrum a eu un effet significatif sur le succès du traitement. Si la concentration de gamma-glutamyl transférase était inférieure à 200 UI / L chez les veaux âgés de moins de 4 jours, le taux de guérison était significativement différent du taux de guérison de patients suffisamment immunisés (26,9% (7 sur 26) contre 65,3% (47 sur 72), p = 0,001).

Age-based differences in the disability of extremity injuries in pediatric and adult occupants.

Objective: The objective was to develop a disability-based metric for motor vehicle crash (MVC) upper and lower extremity injuries and compare functional outcomes between children and adults.Methods: Disability risk (DR) was quantified using Functional Independence Measure (FIM) scores within the National Trauma Data Bank-Research Data System for the top 95% most frequently occurring Abbreviated Injury Scale (AIS) 3 extremity injuries (22 unique injuries). Pediatric (7-18 years), young adult (19-45 years), middle-aged (46-65 years), and older adult (66+ years) MVC occupants with an FIM score and at least one of the 22 extremity injuries were included. DR was calculated for each injury as the proportion of occupants who were disabled of those sustaining the injury. A maximum AIS-adjusted disability risk (DRMAIS) was also calculated for each injury, excluding occupants with AIS 4+ co-injuries.Results: Locomotion impairment was the most frequent disability type across all ages. DR and DRMAIS of the extremity injuries ranged from 0.06 to 1.00 (6%-100% disability risk). Disability risk increased with age, with DRMAIS increasing from 25.9% ± 8.6% (mean ± SD) in pediatric subjects to 30.4% ± 6.3% in young adults, 39.5% ± 6.6% in middle-aged adults, and 60.5 ± 13.3% in older adults. DRMAIS for upper extremity fractures differed significantly between age groups, with higher disability in older adults, followed by middle-aged adults. DRMAIS for pelvis, hip, shaft, knee, and other lower extremity fractures differed significantly between age groups, with older adult DRMAIS being significantly higher for each fracture type. DRMAIS for hip and lower extremity shaft fractures was also significantly higher in middle-aged occupants compared to pediatric and young adult occupants. The maximum AIS-adjusted mortality risk (MRMAIS, proportion of fatalities among occupants sustaining an MAIS 3 injury) was not correlated with DRMAIS for extremity injuries in pediatric, young adult, middle-aged, and older adult occupants (all R2 < 0.01). Disability associated with each extremity injury was higher than mortality risk.Conclusions: Older adults had significantly greater disability for MVC extremity injuries. Lower disability rates in children may stem from their increased physiological capacity for bone healing and relative lack of bone disease. The disability metrics developed can supplement AIS and other severity-based metrics by accounting for the age-specific functional implications of MVC extremity injuries.

Comparison of Cone-Beam Computed Tomography and Multislice Computed Tomography in the Assessment of Extremity Fractures.

OBJECTIVES: The aims of this study were to evaluate the agreement between cone-beam computed tomography (CBCT) and multislice computed tomography for the characterization of extremity fractures and to compare image quality, radiation dose, and patient tolerance. METHODS: Thirty-six patients with suspected fracture affecting distal extremities or who required preoperative fracture assessment were enrolled prospectively. Each patient underwent CBCT and multislice computed tomography the same day. Both examinations were evaluated independently twice by 2 trained radiologists using the Müller AO classification for fracture characterization. RESULTS: Cohen κ coefficient for agreement between the imaging techniques was almost perfect for fracture characterization, κ = 0.94 [95% confidence interval, 0.91-0.98]. There was substantial to almost perfect agreement for secondary findings. Cone-beam computed tomography was well tolerated and significantly less irradiant and had better subjective image. CONCLUSIONS: An excellent agreement between both imaging techniques was found. This confirms the ability of CBCT to assess fractures and its potential in the management of patients with distal limb trauma.

Hypoalbuminemia Is an Independent Risk Factor for 30-Day Mortality, Postoperative Complications, Readmission, and Reoperation in the Operative Lower Extremity Orthopaedic Trauma Patient.

INTRODUCTION: Malnutrition, as indicated by hypoalbuminemia, is known to have detrimental effects on outcomes after arthroplasty, geriatric hip fractures, and multiple general surgeries. Hypoalbuminemia has been examined in the critically ill but has largely been ignored in the orthopaedic trauma literature. We hypothesized that admission albumin levels would correlate with postoperative course in the nongeriatric lower extremity trauma patient. METHODS: Patients with lower extremity (including pelvis and acetabulum) fracture who underwent operative intervention were collected from the ACS-NSQIP database. Patients younger than 65 years were included. Patient demographic data, complications, length of stay, reoperation rate, and readmission rate were collected, and patient modified frailty index scores were calculated. Poisson regression with robust error variance was then conducted, controlling for potential confounders. RESULTS: Five thousand six hundred seventy-three patients with albumin available were identified, and 29.6% had hypoalbuminemia. Hypoalbuminemic patients had higher rates of postoperative complications [9.3% vs. 2.6%; relative risk (RR) 1.63] including increased rates of: mortality (3.2% vs. 0.4%; RR 4.86, 95% confidence interval 2.66-8.87), sepsis (1.5% vs. 0.5%, RR 2.35), and reintubation (2.3% vs. 0.4%; RR 3.84). Reoperation (5.5% vs. 2.6%, RR 1.74) and readmission (11.4% vs. 4.1%; RR 2.53) rates were also higher in patients with low albumin. CONCLUSION: Hypoalbuminemia is a powerful predictor of acute postoperative course and mortality after surgical fixation in nongeriatric, lower extremity orthopaedic trauma patients. Admission albumin should be a routine part of the orthopaedic trauma workup. Further study into the utility of supplementation is warranted, as this may represent a modifiable risk factor. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The effectiveness of ultrasound in the detection of fractures in adults with suspected upper or lower limb injury: a systematic review and subgroup meta-analysis.

BACKGROUND: The aim of the present review is to assess the effectiveness of ultrasound (US) in the detection of upper and lower limb bone fractures in adults compared to a diagnostic gold standard available in secondary and tertiary care centres (e.g. radiography, CT scan or MRI). METHODS: The review followed PRISMA guidelines and used a database-specific search strategy with Medline, EMBASE and The Cochrane Library plus secondary sources (see supplementary material for completed PRISMA checklist). Diagnostic performance of ultrasound was assessed with a qualitative synthesis and a meta-analysis of two data subgroups. RESULTS: Twenty-six studies were included (n = 2360; fracture prevalence =5.3 % to 75.0%); data were organised into anatomical subgroups, two of which were subjected to meta-analysis. Sensitivity and specificity ranged from 42.11 - 100% and 65.0 - 100%, with the highest diagnostic accuracy in fractures of the foot and ankle. The pooled sensitivity and specificity of US was 0.93 and 0.92 for upper limb fractures (I2 = 54.7 % ; 66.3%), and 0.83 and 0.93 for lower limb fractures (I2 = 90.1 % ; 83.5%). CONCLUSION: Ultrasonography demonstrates good diagnostic accuracy in the detection of upper and lower limb bone fractures in adults, especially in fractures of the foot and ankle. This is supported by pooled analysis of upper and lower limb fracture subgroups. Further research in larger populations is necessary to validate and strengthen the quality of the available evidence prior to recommending US as a first-line imaging modality for prehospital use. TRIAL REGISTRATION: The protocol is registered with the PROSPERO International register of systematic reviews: ID = CRD42017053640 .

Change in Pain Score after Administration of Analgesics for Lower Extremity Fracture Pain during Hospitalization.

BACKGROUND: Effective acute pain management following injury is critical to improve short-and long-term patient outcomes. Analgesics can effectively reduce pain intensity, yet half of injury patients report moderate to severe pain during hospitalization. PURPOSE: The primary aim of this study was to identify the analgesic, different analgesic combinations, or analgesic and adjuvant analgesic combination that generated the largest percent change from pre- to post-analgesic pain score. DESIGN: This was a descriptive retrospective cohort study of 129 adults admitted with lower extremity fractures to a trauma center. METHODS: Name, dose, and frequency of analgesics and adjuvant analgesics administered from admission to discharge were collected from medical records. Percent change was calculated from pain scores documented on the 0-10 numeric rating scale. RESULTS: The analgesic with largest percent change from pre- to post-administration pain score was hydromorphone 2 mg IV (53%) for the emergency department and morphine 4 mg IV (54%) for the in-patient unit. All analgesics administered in the emergency department and ∼50% administered on the in-patient unit produced a minimal (15%) decrease in pain score. CONCLUSIONS: This study revealed that few analgesics administered in the emergency department and the in-patient unit to patients with lower extremity fractures provide adequate pain relief. In the emergency department, all analgesics administered resulted in at least minimal improvement of pain. On the in-patient unit 13 analgesic doses resulted at least minimal improvement in pain while nine doses did not even reach 20% change in pain. Findings from this study can be used guide the treatment of fracture pain in the hospital.

Metabolic bone disease risk factors strongly contributing to long bone and rib fractures during early infancy: A population register study.

BACKGROUND: The aim of this study was to assess the incidence of fractures in infancy, overall and by type of fracture, its association with accidents, metabolic bone disease risk factors, and abuse diagnosis. METHODS: The design was a population-based register study in Sweden. Participants: Children born 1997-2014, 0-1 years of age diagnosed with fracture-diagnosis according to International Classification of Diseases (ICD10) were retrieved from the National Patient Register and linked to the Swedish Medical Birth Register and the Death Cause Register. Main outcome measures were fractures of the skull, long bone, clavicle and ribs, categorized by age (younger or older than 6 months), and accident or not. FINDINGS: The incidence of fractures during infancy was 251 per 100 000 infants (n = 4663). Major fracture localisations were long bone (44·9%), skull (31·7%), and clavicle (18·6%), while rib fractures were few (1·4%). Fall accidents were reported among 71·4%. One-third occurred during the first 6 months. Metabolic bone disease risk factors, such as maternal obesity, preterm birth, vitamin D deficiency, rickets, and calcium metabolic disturbances, had increased odds of fractures of long bones and ribs in early infancy (0-6 months): birth 32-36 weeks and long bone fracture [AOR 2·13 (95%CI 1·67-2·93)] and rib fracture [AOR 4·24 (95%CI 1·40-12·8)]. Diagnosis of vitamin D deficiency/rickets/disorders of calcium metabolism had increased odds of long bone fracture [AOR 49·5 (95%CI 18·3-134)] and rib fracture [AOR 617 (95%CI 162-2506)]. Fractures without a reported accident had higher odds of metabolic risk factors than those with reported accidents. Abuse diagnosis was registered in 105 infants, with overrepresentation of preterm births, multiple births and small-for-gestational age. INTERPRETATION: Metabolic bone disease risk factors are strongly associated with fractures of long bone and ribs in early infancy. Fracture cases with abuse diagnosis had a metabolic bone risk factor profile.

Abaloparatide versus teriparatide: a head to head comparison of effects on fracture healing in mouse models.

Background and purpose - Teriparatide accelerates fracture healing in animals and probably in man. Abaloparatide is a new drug with similar although not identical effects on the teriparatide receptor. Given at 4 times the teriparatide dose in a human osteoporosis trial, abaloparatide increased bone density more than teriparatide, and both reduced fracture risk. We investigated in mice whether abaloparatide stimulates fracture healing, and if it does so with the suggested dose effect relation (4:1). Patients and methods - In a validated mouse model for metaphyseal healing (burr hole with screw pull-out), 96 mice were randomly allocated to 11 groups: control (saline), teriparatide or abaloparatide, where teriparatide and abaloparatide were given at 5 different doses each. In a femoral shaft osteotomy model, 24 mice were randomly allocated to 3 groups: control (saline), teriparatide (15 µg/kg) or abaloparatide (60 µg/kg). Each treatment was given daily via subcutaneous injections. Results were evaluated by mechanical testing and microCT. Results - In the metaphyseal model, a dose-dependent increase in screw pull-out force could be seen. In a linear regression analysis (r = 0.78) each increase in ln(dose) by 1 (regardless of drug type) was associated with an increase in pull-out force by 1.50 N (SE 0.18) (p < 0.001). Changing drug from teriparatide to abaloparatide increased the force by 1.41 N (SE 0.60; p = 0.02). In the diaphyseal model, the callus density was 23% (SD 10), 38% (SD 10), and 47% (SD 2) for control, for teriparatide and abaloparatide respectively. Both drugs were significantly different from controls (p = 0.001 and p = 0.008), but not from each other. Interpretation - Both drugs improve fracture healing, but in these mouse models, the potency per µg of abaloparatide seems only 2.5 times that of teriparatide, rather than the 4:1 relation chosen in the clinical abaloparatide-teriparatide comparison trial.

Motorcyclists and pillion passengers with open lower-limb fractures: a study using TARN data 2007-2014.

Introduction We aimed to identify population demographics of motorcyclists and pillion passengers with isolated open lower-limb fractures, to ascertain the impact of the revised 2009 British Orthopaedic Association/British Association of Plastic Reconstructive and Aesthetic Surgeons joint standards for the management of open fractures of the lower limb (BOAST 4), in terms of time to skeletal stabilisation and soft-tissue coverage, and to observe any impact on patient movement. Methods Retrospective cohort data was collected by the Trauma Audit and Research Network (TARN). A longitudinal analysis was performed between two timeframes in England (pre-and post-BOAST 4 revision): 2007-2009 and 2010-2014. Results A total of 1564 motorcyclists and 64 pillion passengers were identified. Of these, 93% (1521/1628) were male. The median age for males was 30.5 years and 36.7 years for females. There was a statistically significant difference in the number of patients who underwent skeletal stabilisation (49% vs 65%, P < 0.0001), the time from injury to skeletal stabilisation (7.33 hours vs 14.3 hours, P < 0.0001) and the proportion receiving soft-tissue coverage (26% vs 43%, P < 0.0001). There was no difference in the time from injury to soft-tissue coverage (62.3 hours vs 63.7 hours, P = 0.726). The number of patients taken directly to a major trauma centre (or its equivalent) increased between the two timeframes (12.5% vs, 41%, P < 0.001). Conclusions Since the 2009 BOAST 4 revision, there has been no difference in the time taken from injury to soft-tissue coverage but the time from injury to skeletal stabilisation is longer. There has also been an increase in patient movement to centres offering joint orthopaedic and plastic care.

Prophylactic negative pressure wound therapy after lower extremity fracture surgery: a pilot study.

PURPOSE: Infectious complications following lower extremity fracture surgery are a major concern and account for a substantial socio-economic burden to society. The aim of this pilot study was to investigate the feasibility of a new portable single-use negative pressure wound therapy device in patients undergoing major foot ankle surgery. METHODS: Patients undergoing major foot ankle fracture surgery at a single level 1 trauma centre were eligible for this prospective case series. Patient characteristics were collected, as were fracture and surgical characteristics. Primary outcome was surgical site infection within 30 days as classified by the criteria from the Centers for Disease Control and Prevention. Patients in the prospective cohort were case-matched with a historical cohort from the same institution. RESULTS: Sixty patients were included. In seven patients, the NPWT failed and treatment was ceased. Mean age was 44 years and 85% was ASA 1; 43% of the patients were actively smoking. Indications for surgery were midfoot, calcaneal, talar, and ankle fractures. In 53 patients, four (7.5%) surgical site infections occurred, two superficial (3.3%) and two (3.3%) deep infections. For 47 patients, a match was available. The incidence of surgical site infection did not statistically significantly differ between the prospective cohort and retrospective matched cohort (4.3 versus 14.9%, p = 0.29, respectively). This was also the case when looking at superficial and deep surgical site infections separately (0 versus 8.5%, p = 0.08, and 4.3 versus 6.4%, respectively). CONCLUSION: We have observed surgical site infections in 7.5% of the patients with the use of prophylactic negative pressure wound therapy. The incidence of surgical site infections was not statistically significantly lower compared to a matched historical cohort.

Weight-bearing recommendations after operative fracture treatment-fact or fiction? Gait results with and feasibility of a dynamic, continuous pedobarography insole.

PURPOSE: Rehabilitation after lower-extremity fractures is based on the physicians' recommendation for non-, partial-, or full weight-bearing. Clinical studies rely on this assumption, but continuous compliance or objective loading rates are unknown. The purpose of this study was to determine the compliance to weight-bearing recommendations by introducing a novel, pedobarography system continuously registering postoperative ground forces into ankle, tibial shaft and proximal femur fracture aftercare and test its feasibility for this purpose. METHODS: In this prospective, observational study, a continuously measuring pedobarography insole was placed in the patients shoe during the immediate post-operative aftercare after ankle, tibial shaft and intertrochanteric femur fractures. Weight-bearing was ordered as per the institutional standard and controlled by physical therapy. The insole was retrieved after a maximum of six weeks (28 days [range 5-42 days]). Non-compliance was defined as a failure to maintain, or reach the ordered weight-bearing within 30%. RESULTS: Overall 30 patients were included in the study. Fourteen (47%) of the patients were compliant to the weight-bearing recommendations. Within two weeks after surgery patients deviated from the recommendation by over 50%. Sex, age and weight did not influence the performance (p > 0.05). Ankle fracture patients (partial weight-bearing) showed a significantly increased deviation from the recommendation (p = 0.01). CONCLUSIONS: Our study results show that, despite physical therapy training, weight-bearing compliance to recommended limits was low. Adherence to the partial weight-bearing task was further decreased over time. Uncontrolled weight-bearing recommendations should thus be viewed with caution and carefully considered as fiction. The presented insole is feasible to determine weight bearing continuously, could immediately help define real-time patient behaviour and establish realistic, individual weight-bearing recommendations.

Thrombin-antithrombin III complex tests.

PURPOSE: Patients with fractures of the pelvis and/or lower extremities are at a high risk of developing postoperative venous thromboembolism (VTE). The purpose of this study was to determine whether the thrombin-antithrombin III complex (TAT) tests could be used for postoperative screening of VTE in patients with lower limb or pelvic fractures. METHODS: We enrolled 133 patients who underwent surgical treatment for fracture of the pelvis or lower extremities. TAT and D-dimer levels were compared in patients with and without VTE. Receiver operating characteristic (ROC) curve analysis was done and the appropriate TAT and D-dimer cutoff levels were determined for VTE screening. RESULTS: VTE was diagnosed in 41 patients (30.8%). Patients with VTE had significantly higher levels of TAT and D-dimer on postoperative days 1, 3, and 7 than those without VTE, respectively. ROC curve analysis suggested that TAT test at postoperative day 7 had the highest accuracy for predicting postoperative VTE. With the optimal cutoff TAT level of 3.0 ng/mL, sensitivity and specificity were 93.3% and 70.1%, respectively. With the optimal cutoff D-dimer level of 7.4 µg/mL, sensitivity and specificity were 93.3% and 57.0%, respectively. CONCLUSION: TAT levels measured at postoperative day 7 could be the most useful parameter for screening postoperative VTE. TAT can be used as a screening tool for screening postoperative VTE in patients with lower limb and pelvic fractures.

Psychometric properties of the Dutch Short Musculoskeletal Function Assessment (SMFA) questionnaire in severely injured patients.

UNLABELLED: In this cross-sectional study the psychometric properties are examined of the adapted Dutch translation of the Short Musculoskeletal Function Assessment (SMFA) questionnaire in severely injured patients (ISS>15). PATIENTS AND METHODS: Patients (N=173) completed the SMFA, the World Health Organization Quality of Life assessment instrument-BREF (WHOQOL-BREF), the Dutch Impact of Event Scale (IES), the Hospital Anxiety and Depression Scale (HADS) and the Cognitive Failure Questionnaire (CFQ). The Abbreviated Injury Score and the Injury Severity Score were established to determine the injured body area and the severity of the injuries. Exploratory factor analysis (method: PAF) was performed. Correlations were calculated between our SMFA factors and scores on the WHOQOL-BREF, IES, HADS and CFQ. The SMFA scores of the factors Upper extremity dysfunction and Lower extremity dysfunction were compared between subgroups of patients with and without injuries in respectively the upper extremities and the lower extremities. For responsiveness analysis, data were compared with the baseline SMFA measurement of a reference group. RESULTS: A three-factor structure was found: Lower extremity dysfunction, Upper extremity dysfunction, and Emotion. Strong correlations between the SMFA and the other questionnaires were found. Patients with injury of the lower extremities had significantly higher scores on the factor Lower extremity dysfunction than patients without injury of the lower extremities (p=0.017). In none of the factors, a significant difference in mean scores was found between patients with and without injury of the upper extremities. Severely injured patients had significantly higher SMFA scores than the reference group (p<0.001). CONCLUSION: The adapted Dutch translation of the SMFA showed good psychometric properties in severely injured patients. It appeared to be useful to get a general overview of patients' Health Status as well as patients' Health Related Quality Of Life.

Observed Rates of Lower Extremity Stress Fractures After Implementation of the Army Physical Readiness Training Program at JBSA Fort Sam Houston.

Millions of dollars are lost each year to the US military in medical discharges from injuries sustained in the initial training of recruits. Most medical discharges in recruits are related to musculoskeletal overuse injuries, including stress fractures. Any strategies that can reduce injury rates are also likely to reduce rates of medical discharge. This study evaluated the Army Physical Readiness Training (PRT) program which was established to provide a method of physical fitness training that would reduce the number of preventable injuries. We conducted a retrospective study to evaluate the number of lower extremity stress fractures that were diagnosed in the 6 months prior to and 6 months following the implementation of the PRT program. Electronic medical records were queried for specific diagnoses of stress fractures to the pelvis, femoral neck, femoral shaft, tibia, fibula, tarsals and metatarsals. The observed number of diagnoses in each time period were compared using the χ² method. Decrease was shown not only in the overall occurrence of stress fractures, but specifically in the occurrence of stress fractures of the femoral neck, femoral shaft, and tarsals. Our study was able to show a correlation between the PRT program and a decrease in the observed occurrence of lower extremity stress fractures.