The classification algorithms to support the management of the patient with femur fracture.

Effectiveness in health care is a specific characteristic of each intervention and outcome evaluated. Especially with regard to surgical interventions, organization, structure and processes play a key role in determining this parameter. In addition, health care services by definition operate in a context of limited resources, so rationalization of service organization becomes the primary goal for health care management. This aspect becomes even more relevant for those surgical services for which there are high volumes. Therefore, in order to support and optimize the management of patients undergoing surgical procedures, the data analysis could play a significant role. To this end, in this study used different classification algorithms for characterizing the process of patients undergoing surgery for a femoral neck fracture. The models showed significant accuracy with values of 81%, and parameters such as Anaemia and Gender proved to be determined risk factors for the patient's length of stay. The predictive power of the implemented model is assessed and discussed in view of its capability to support the management and optimisation of the hospitalisation process for femoral neck fracture, and is compared with different model in order to identify the most promising algorithms. In the end, the support of artificial intelligence algorithms laying the basis for building more accurate decision-support tools for healthcare practitioners.

Sinusoidal alternating electromagnetic field accelerates fracture healing in rats. / æ­£å¼¦äº¤å˜ç”µç£åœºå¯åŠ é€Ÿå¤§é¼ éª¨æŠ˜æ„ˆåˆ.

OBJECTIVES: To investigate the effect of sinusoidal alternating electromagnetic field (SEMF) on fracture healing and its mechanism. METHODS: Femoral fracture model was established using specific pathogen free male Wistar rats. Thirty rats were randomly divided into the control and SEMF groups with 15 rats in each group. The SEMF group was given 50 Hz 1.8 mT for 90 min every day, while the control group was not treated. X-ray examinations were performed every two weeks to determine the formation of bone scabs. Three rats from both groups were sacrificed after 2 and 4 weeks of treatment. Protein was extracted from the fractured femurs, and the expression of type Ⅰ collagen (COL-1), osterix (OSX), Runt-related transcription factor 2 (RUNX2), and vascular endothelial growth factor (VEGF) was detected by Western blotting. After 8 weeks, the femur on the operated side was taken for micro-CT scanning to observe fracture healing, angiography to observe blood vessel growth, and organs such as hearts, livers, spleens, lungs, and kidneys were taken for safety evaluation by hematoxylin-eosin staining (HE staining). RESULTS: The bone scab scores of the SEMF group were significantly higher than those of the control group after 2, 4, 6, and 8 weeks of treatment (all P<0.01). The fracture healing of the SEMF group was better than that of the control group after 8 weeks, and the bone volume scores of the two groups were 0.243±0.012 and 0.186±0.008, respectively (P<0.01); the number of blood vessels in the SEMF group was also more than that of the control group after 8 weeks. Western blotting results showed that the expressions of COL-1, OSX, RUNX2, and VEGF were higher in the SEMF group than those in the control group after 2 and 4 weeks of treatment (all P<0.05). HE staining showed that histopathological results of the examined organs were normal in both groups. CONCLUSIONS: SEMF can accelerate fracture healing by promoting the expression of osteogenic factors and vascular proliferation without significant adverse effects.

Low-intensity pulsed ultrasound partially reversed the deleterious effects of a severe spinal cord injury-induced bone loss and osteoporotic fracture healing in paraplegic rats.

PURPOSE: To evaluate the effects of low-intensity pulsed ultrasound (LIPUS) on the quality of femoral fracture callus formation in rats with severe osteoporosis secondary to spinal cord injury (SCI). METHODS: Forty-five male rats were equally divided into three groups: the Sham group underwent sham surgery for SCI followed by surgery for femoral fracture on day ten post-spine surgery; the SCI group sustained a complete transection of the spinal cord and a femoral fracture ten days post-SCI; and the SCI group treated with ultrasound (SCI + US), which also sustained a femoral fracture on day ten post-SCI, concomitant with daily application of LIPUS at the fracture site. RESULTS: At the non-fractured tibias, LIPUS counteracted the SCI-induced bone loss by normalizing the osteoblastic-related gene expression, decreasing resorptive area, increasing trabecular area, and decreasing RANK and RANK-L-positive areas, which resulted in higher cortical volume and stronger tibias. Likewise, LIPUS was effective at restoring bone fracture healing in SCI rats; by promoting endochondral ossification, increasing collagen deposition and OPG-positive-area, decreasing resorptive area, which led to higher density and improved microarchitecture, ultimately resulting in stronger fracture callus. CONCLUSION: At the tibias, LIPUS counteracted the SCI-induced bone loss effects by simultaneously increasing bone formation and decreasing bone resorption. We also evidenced the osteogenic effects of LIPUS at partially restoring the endochondral ossification during callus formation, leading to a newly formed tissue with improved microarchitecture and mechanical integrity. Therefore, LIPUS may be an efficient and non-invasive approach to prevent bone loss and osteoporotic fracture in SCI individuals.

Epidemiology and associated injuries in paediatric diaphyseal femur fractures treated at a limited resource zonal referral hospital in northern Tanzania.

BACKGROUND: Diaphyseal femur fractures contribute up to 40% of paediatric orthopaedic admissions with the World Health Organisation data showing youth are particularly vulnerable and road traffic injuries are the leading cause of death for children and young adults. Different mechanisms results to these injuries and they vary with age and geographical location of the patient. Understanding the incidence, mechanism and pattern of these injuries allows planning for preventive measures and treatment to meet modern day patient demands, generation of appropriate and timely protocols with minimum social and economic burden to the patient and family. OBJECTIVES AND METHODS: A hospital based cross sectional study was conducted using the orthopaedic department patient registry among children aged under 18 years admitted from 2014-2018. Our research question was to determine the epidemiology of diaphyseal femur fractures and coexisting associated injuries among admitted paediatric orthopaedic patients. Patient files were reviewed from the medical records department and a data collecting sheet was used to record demographics and injury data. Odds ratios with 95% confidence intervals for associated injuries in paediatric diaphyseal femur fractures were estimated using multivariable logistic regression model. RESULTS: We found the prevalence of diaphyseal femur fracture among paediatric orthopaedic admissions was 18% with the majority 111 (68.5%) being males. The leading injury mechanism was a fall (57.4%) followed by road traffic injuries (35.8%) out of which 48.3% resulted from pedestrian vs motorcycle accidents. Traumatic brain injury (TBI) was the most common associated injuries accounting for 69% of these injuries with the majority 79% occurring in patients aged 6 years and older. With age specific analysis, children in 6-12 years and 13-18 years age groups, had 8 and 11 times higher odds for associated injuries (OR 8.25, 95% CI, 1.04-65.31) p = 0.046 and (OR 10.54, 95% CI, 1.26-88.31) p = 0.031 respectively compared to those younger ≤ 2 years. Road traffic related injuries had 17 times higher odds of associated injuries when compared to fall (OR 16.73, 95% CI, 6.28-44.57) p < 0.001. 112 (69.1%) of femur fractures were treated by non-operative method out of this 90 (55.6%) by traction with delayed Spica application. The overall mean duration of hospital stay was 18.5 ± 11 days. CONCLUSION: Pedestrian vs motorcycle injuries was the leading specific cause of paediatric diaphyseal femur fractures with TBI being the common associated injury. Non-operative management was the most utilized treatment plan and contributed to ten times higher odds for a longer duration of hospital stay. Initiatives to insure children safety on roads should be strengthened in order to reduce/eliminate this burden. Application and practice of current evidence based clinical guidelines and recommendations is paramount for timely and appropriate treatment of these injuries.

Lower mortality in distal femoral fractures in the presence of a knee arthroplasty: an observational study on 2,725 fractures from the Swedish Fracture Register.

BACKGROUND AND PURPOSE: Distal femoral fractures (DFF) in older patients have mortality rates comparable to fractures of the proximal femur. An ageing population combined with an increasing number of patients undergoing total knee arthroplasty (TKA) will make periprosthetic distal femoral fractures (pDFF) more common. We investigated whether a pre-existing TKA influences mortality rates. PATIENTS AND METHODS: All patients ≥ 60 years registered in the Swedish Fracture Register with a DFF sustained between March 20, 2011 and December 31, 2020 were included. The study cohort comprised 2,725 patients, of which 650 had a pDFF. Unadjusted 90-day and 1-year mortality was estimated via Kaplan-Meier survival curves. A Cox regression model adjusted for age, sex, and treatment modality was used to investigate the association between DFF or pDFF and mortality. RESULTS: Mean age was 80 years and 82% were females. The most common injury mechanism was a simple fall (75%). The pDFF and DFF group were similar with regards to age, sex, and trauma mechanism. Unadjusted 90-day and 1-year mortality was 11% (95% CI 10-12) and 21% (CI 19-23), respectively. Kaplan-Meier survival analysis demonstrated a slightly lower mortality for pDFFs, especially in patients ≤ 70 years. The Cox regression model showed a lower hazard ratio (HR) for mortality in the pDFF group (HR 0.82, CI 0.71-0.94). INTERPRETATION: In a large cohort of patients ≥ 60 years with a distal femoral fracture, mortality rates at 90 days and 1 year post-injury were 11% and 21%, respectively. Periprosthetic fractures were associated with a lower mortality.

Modification of pore-wall in direct ink writing wollastonite scaffolds favorable for tuning biodegradation and mechanical stability and enhancing osteogenic capability.

Surface chemistry and mechanical stability determine the osteogenic capability of bone implants. The development of high-strength bioactive scaffolds for in-situ repair of large bone defects is challenging because of the lack of satisfying biomaterials. In this study, highly bioactive Ca-silicate (CSi) bioceramic scaffolds were fabricated by additive manufacturing and then modified for pore-wall reinforcement. Pure CSi scaffolds were fabricated using a direct ink writing technique, and the pore-wall was modified with 0%, 6%, or 10% Mg-doped CSi slurry (CSi, CSi-Mg6, or CSi-Mg10) through electrostatic interaction. Modified CSi@CSi-Mg6 and CSi@CSi-Mg10 scaffolds with over 60% porosity demonstrated an appreciable compressive strength beyond 20 MPa, which was ~2-fold higher than that of pure CSi scaffolds. CSi-Mg6 and CSi-Mg10 coating layers were specifically favorable for retarding bio-dissolution and mechanical decay of scaffolds in vitro. In-vivo investigation of critical-size femoral bone defects repair revealed that CSi@CSi-Mg6 and CSi@CSi-Mg10 scaffolds displayed limited biodegradation, accelerated new bone ingrowth (4-12 weeks), and elicited a suitable mechanical response. In contrast, CSi scaffolds exhibited fast biodegradation and retarded new bone regeneration after 8 weeks. Thus, tailoring of the chemical composition of pore-wall struts of CSi scaffolds is beneficial for enhancing the biomechanical properties and bone repair efficacy.

LncRNA KCNQ1OT1 accelerates fracture healing via modulating miR-701-3p/FGFR3 axis.

Emerging evidence highlights the role of the long noncoding RNA (lncRNA) KCNQ1OT1 in fracture healing. Osteoblast proliferation, migration, and survival are pivotal during this process. In this study, we aimed to improve our understanding of the regulatory role of lncRNA KCNQ1OT1 during osteoblast proliferation, migration, and survival. We searched the gene expression omnibus databases and LncBase Experimental V.2 to identify key microRNAs (miRNAs) targets of KCNQ1OT1. MiR-701-3p was selected as a differentially expressed miRNA and RNA immunoprecipitation assays were performed to verify its interaction with KCNQ1OT1. Fibroblast growth factor receptor 3 (FGFR3) was also identified as a target of miR-701-3p. We further identified KCNQ1OT1 as a competing endogenous RNA of miR-701-3p that could influence osteoblast proliferation, migration, and apoptosis in vitro and in vivo. Taken together, our results indicate that the KCNQ1OT1/miR-701-3p/FGFR3 axis is an important regulator of osteoblast proliferation, migration, and apoptosis, and provide a new therapeutic avenue for fracture healing.

Models to predict the probability for intraoperative RBC transfusion during lumbar spinal stenosis and femoral fracture surgeries in aged patients.

OBJECTIVE: The goal of this study was to predict the probability of transfusion of red blood cells and the volume of blood consumption based on the clinical characteristics of patients before surgery. METHODS: The medical records of 565 patients over 65 years old who underwent posterior lumbar surgery and 586 patients over 65 years old receiving femoral fracture surgery were reviewed. The clinical characteristics of the patients were subjected to multivariate regression analysis. The scores of these factors' influences on intraoperative red blood cells infusion were based on the odds ratio of each multivariate risk factor. Non-linear regression was performed to predict the probability of intraoperative blood transfusion and the volume of blood used for patients with different scores. RESULTS: The factors that significantly influenced blood use during lumbar spinal stenosis and femoral fracture surgery in aged patients(P < 0.05) included age, body mass index, abnormal coagulation function, preoperative hemoglobin, administration of antithrombotic drugs, multisegmental lesions of the lumbar spine, femoral shaft fracture, secondary lumbar surgery and the time from fracture to surgery exceeding 48 h. According to our risk scoring system, patients of posterior lumbar surgery scored 0-10 and patients of femoral fracture had a score of 0-12. More than 50 % of patients receiving an intraoperative red blood cells transfusion during surgery scored>1. CONCLUSION: The scoring system can be used as a predictive model for the probability of red blood cells transfusion and the blood volume in aged patients undergoing lumbar spinal stenosis and femoral fracture surgeries.

Incidence and treatment of adult femoral fractures with osteogenesis imperfecta: An analysis of a center of 72 patients in Taiwan.

Background: Osteogenesis imperfecta (OI) is a rare disease characterized by increased bone fragility and susceptibility for fractures. Only few studies have compared the management for femoral fractures in children with OI. Nevertheless, no cohort studies have described the treatment for femoral fractures in adults with OI in Taiwan. This study aimed to investigate and compare the incidence of union and non-union femoral fractures and the best treatment options to avoid non-union fractures. Methods: We enrolled 72 patients with OI who were older than 18 years at MacKay Memorial Hospital between January 2010 and December 2018. Femoral fracture incidence, non-union rate, and treatment modality were analyzed. Results: Of 72 patients with OI, 11 patients had femoral fractures and 4 patients of them had >1 femoral fracture. The incidence for all types of femoral fractures was 651 fractures per 100,000 person-years annually. In 15 total fractures, 4 fractures resulted in non-union, and patients with type 4 OI mostly had shaft fractures. The best outcomes for non-union shaft fracture is achieved by surgical treatment. Conclusion: Adults with OI tended to develop femoral fractures and non-unions. Adults with type 4 OI were particularly at high risk for non-unions in shaft fractures with conservative treatment.

Finite Element Analysis of Fracture Fixation.

PURPOSE OF REVIEW: Fracture fixation aims to provide stability and promote healing, but remains challenging in unstable and osteoporotic fractures with increased risk of construct failure and nonunion. The first part of this article reviews the clinical motivation behind finite element analysis of fracture fixation, its strengths and weaknesses, how models are developed and validated, and how outputs are typically interpreted. The second part reviews recent modeling studies of the femur and proximal humerus, areas with particular relevance to fragility fractures. RECENT FINDINGS: There is some consensus in the literature around how certain modeling aspects are pragmatically formulated, including bone and implant geometries, meshing, material properties, interactions, and loads and boundary conditions. Studies most often focus on predicted implant stress, bone strain surrounding screws, or interfragmentary displacements. However, most models are not rigorously validated. With refined modeling methods, improved validation efforts, and large-scale systematic analyses, finite element analysis is poised to advance the understanding of fracture fixation failure, enable optimization of implant designs, and improve surgical guidance.

Citrate-based materials fuel human stem cells by metabonegenic regulation.

A comprehensive understanding of the key microenvironmental signals regulating bone regeneration is pivotal for the effective design of bioinspired orthopedic materials. Here, we identified citrate as an osteopromotive factor and revealed its metabonegenic role in mediating citrate metabolism and its downstream effects on the osteogenic differentiation of human mesenchymal stem cells (hMSCs). Our studies show that extracellular citrate uptake through solute carrier family 13, member 5 (SLC13a5) supports osteogenic differentiation via regulation of energy-producing metabolic pathways, leading to elevated cell energy status that fuels the high metabolic demands of hMSC osteodifferentiation. We next identified citrate and phosphoserine (PSer) as a synergistic pair in polymeric design, exhibiting concerted action not only in metabonegenic potential for orthopedic regeneration but also in facile reactivity in a fluorescent system for materials tracking and imaging. We designed a citrate/phosphoserine-based photoluminescent biodegradable polymer (BPLP-PSer), which was fabricated into BPLP-PSer/hydroxyapatite composite microparticulate scaffolds that demonstrated significant improvements in bone regeneration and tissue response in rat femoral-condyle and cranial-defect models. We believe that the present study may inspire the development of new generations of biomimetic biomaterials that better recapitulate the metabolic microenvironments of stem cells to meet the dynamic needs of cellular growth, differentiation, and maturation for use in tissue engineering.

Webril-only Soft Spica Cast for Pediatric Femoral Fractures: A Preliminary Study.

We report using a spica cast created with cotton padding and Ace wrap without a rigid component for femur fracture in infants. Outcomes and complications of this soft spica cast were retrospectively compared with other treatments. There were 43 children younger than 6 months (43 diaphyseal fractures) included in the study. Treatment was a Pavlik harness (26 patients), a hard spica cast (8), or a soft spica cast (9) for an average of 3 weeks. All fractures demonstrated healing with similar final angulation and shortening. Hard spica casts caused the most complications. As for material costs, the soft spica is the least costly method ($2 per cast versus $87-$107 for Pavlik harness and $150 for hard spica). In conclusion, soft spica casts are as effective as other treatment options for femoral shaft fractures in young children. These casts are advantageous since they are easier to apply, easier to manage, and have a lower cost. (Journal of Surgical Orthopaedic Advances 30(1):040-043, 2021).

A RETROSPECTIVE STUDY OF FEMORAL FRACTURES IN WILD BIRDS OF PREY: 119 CASES.

A retrospective study was performed to describe patient and fracture characteristics, treatments, complications, and outcomes associated with femoral fractures in free-ranging birds of prey. Cases were identified from the electronic database and included raptors admitted with femoral fractures at the Bird of Prey Clinic of the Université de Montréal, from 1986 to 2018. In total, 119 individuals from 24 species, with 123 femoral fractures, were included in the study. Twenty-seven birds (23%) were declared dead upon arrival. Ninety-two birds (77%) were admitted alive; 80 with acute fractures and 12 with a fracture that had already healed. A conservative treatment (cage rest) was used to manage eight fractures. Surgical repair was attempted on 34 femoral fractures in 33 birds. An intramedullary pin alone was used in 28 cases (82%), and an external skeletal fixator-intramedullary pin tie-in fixator was used in 6 cases (18%). For surgically treated fractures, 19 healed (in 18 birds), 4 did not heal, and 11 birds died or were euthanized before healing could be achieved. Of the 23/34 fractures where the healing process could be assessed, healing rate for comminuted fractures (11/23) was 91% (10/11). Surgical complications occurred in 10 cases (including 7 cases of migration and loosening of the pin, and 1 case of osteomyelitis), leading to euthanasia in 4 cases. Out of the 21 birds with acute femoral fracture upon presentation that were released, 14 had received a surgical treatment and 7 had received a conservative treatment. Nine of the 21 released birds (43%) had at least one other fractured bone. The majority of deaths and euthanasia occurred within 2 wk after admission (51/59; 86%). Thirteen birds were euthanized primarily because of their femoral fracture. Thirteen birds died in treatment and 33 were deemed nonreleasable and euthanized because of a comorbidity not related to the femoral fracture.

Extracorporeal shock wave therapy accelerates endochondral ossification and fracture healing in a rat femur delayed-union model.

Extracorporeal shock wave therapy (ESWT) has been demonstrated to accelerate bone healing; however, the mechanism underlying ESWT-induced bone regeneration has not been fully elucidated. This study aimed to examine the effects of ESWT and the process of fracture healing. A rat model of femur delayed-union was established by cauterizing the periosteum. ESWT treatment at the fracture site was performed 2 weeks after the operation and the site was radiographically and histologically evaluated at weeks 4, 6, and 8. The bone union rate and radiographic score of the ESWT group were significantly higher than those of the control group at 8 weeks. Histological evaluation revealed enhanced endochondral ossification at the fracture site. The effects of ESWT on ATDC5 cells were examined in vitro. ESWT promoted chondrogenic differentiation without inhibiting the proliferation of ATDC5 cells. ESWT may induce significant bone healing by promoting endochondral ossification at the fracture site.

M2 Macrophagy-derived exosomal miRNA-5106 induces bone mesenchymal stem cells towards osteoblastic fate by targeting salt-inducible kinase 2 and 3.

BACKGROUND: Osteoblast differentiation is a vital process for fracture healing, and exosomes are nanosized membrane vesicles that can deliver therapeutic drugs easily and safely. Macrophages participate in the regulation of various biological processes in vivo, and macrophage-derived exosomes (MD-Exos) have recently been a topic of increasing research interest. However, few study has explored the link between MD-Exos and osteoblast differentiation. Herein, we sought to identify miRNAs differentially expressed between M1 and M2 macrophage-derived exosomes, and to evaluate their roles in the context of osteoblast differentiation. RESULTS: We found that microRNA-5106 (miR-5106) was significantly overexpressed in M2 macrophage-derived exosomes (M2D-Exos), while its expression was decreased in M1 macrophage-derived exosomes (M1D-Exos), and we found that this exosomal miRNA can induce bone mesenchymal stem cell (BMSC) osteogenic differentiation via directly targeting the Salt-inducible kinase 2 and 3 (SIK2 and SIK3) genes. In addition, the local injection of both a miR-5106 agonist or M2D-Exos to fracture sites was sufficient to accelerate healing in vivo. CONCLUSIONS: Our study demonstrates that miR-5106 is highly enriched in M2D-Exos, and that it can be transferred to BMSCs wherein it targets SIK2 and SIK3 genes to promote osteoblast differentiation.

Characteristics and Hospital Costs of Spica Cast Treatment of Non-accidental-related Diaphyseal Femoral Fractures in Children Before Walking Age.

BACKGROUND: Fractures are one of the most common presentations of child abuse second only to soft tissue damage, with ∼60% of fractures being femur, humerus or tibia fractures. Although studies have shown increased health care costs associated with nonaccidental trauma (NAT), there is little data regarding the cost of NAT-associated fractures compared with accidental trauma (AT) related fractures. The purpose of this study was to consider the economic burden of NAT related femoral fractures compared with AT femoral fractures. METHODS: We performed a retrospective study of children under the age of one with femoral fractures treated with a spica cast at a Level 1 Pediatric Trauma Center between 2007 and 2016. Variables included age, sex, length of hospital stay, and estimated total billing cost obtained from this hospital's billing department. In addition, fracture site (mid-shaft, distal, proximal, and subtrochanteric) and pattern were assessed. RESULTS: Sixty children with a mean age of 7 months were analyzed. NAT was suspected in 19 cases (31.7%) and confirmed in 9 (15%) before discharge. Two groups were analyzed: the NAT group included suspected and confirmed cases of abuse (28) and the AT group contained the remaining 32 cases. There was no significant difference in the demographics between these 2 groups. Children in NAT group had a longer length of stay compared with AT group (78.9 vs. 36.7 h, P<0.001). Overall consumer price index-adjusted hospital costs were $24,726 higher for NAT group compared with AT group (P=0.024), with costs of laboratory workup, radiology, and nonorthopaedic physician fees being the top 3 components contributing to the increased costs. CONCLUSIONS: The overall incidence of NAT was 46.6% in children presenting with femoral fracture under 1 year of age. The overall hospital cost of treating fractures in the NAT group was 1.5 times higher than the AT group, with imaging charges the most significant contributor to cost difference. LEVEL OF EVIDENCE: Level III-retrospective review.

Practice Patterns for Management of Pediatric Femur Fractures in Low- and Middle-Income Countries.

BACKGROUND: Femoral shaft fractures in children are common in low and middle income countries. In high-income countries, patient age, fracture pattern, associated injuries, child/family socioeconomic status, and surgeon preference dictate fracture management. There is limited literature on treatment patterns for pediatric femur fractures in resource-limited settings. This study surveys surgeons from low (LIC), lower-middle (LMIC), and upper-middle income (UMIC) countries regarding treatment patterns for pediatric femur fractures. METHODS: Surgeons completed an electronic survey reporting surgeon demographics and treatment preference for pediatric femur fractures. Treatment preferences and indications for treatment were separated into 4 groups: infant (0 to 6 mo); toddler (7 mo to 4 y); child (5 to 12 y); adolescent (12 to 17 y). The survey was available in English, Spanish, and French. Analysis was completed with t test and χ test for continuous and categorical variables, respectively, and weighted Pearson correlation (P<0.05). RESULTS: Survey respondents consisted of 413 surgeons from 83 countries (20 LIC, 33 LMIC, 30 UMIC). The majority of respondents were fellowship trained (83%) most commonly in pediatrics (26%) and trauma (43%). Most treated >10 pediatric femur fractures per year (68%). Respondents reported treating infant femur fractures nonoperatively using Pavlik harness (19%), spica cast (60%), or traction with delayed spica cast (14%). Decreasing socioeconomic status was associated with higher nonoperative treatment rate in toddlers, children, and adolescents. Respondents commonly utilize bed rest and traction for child femur fractures in LICs (63%) and LMICs (65%) compared with UMICs (35%) (UMIC vs. LMIC P<0.001; UMIC vs. LIC P<0.001). Surgeries in children more commonly involve open reduction with internal fixation (UMIC 19%, LMIC 33%, LIC 40%; P<0.05 between UMIC-LMIC and UMIC-LIC). CONCLUSION: This is one of the largest surveys describing treatment patterns for pediatric femur fractures in low and middle income countries. Differences are evident including lower operative treatment rate in younger children and lower intramedullary fixation rates in older children. Future studies should investigate the value of treatment options in resource-limited settings. LEVEL OF EVIDENCE: Level II-prospective comparative study.

Does the induced membrane have antibacterial properties? An experimental rat model of a chronic infected nonunion.

INTRODUCTION: The Masquelet procedure proved its efficiency in treating infected nonunion filling bony gaps up to 25 cm. Yet the use of local antibiotics is still questionable in the daily practice with lack of evidence regarding its usefulness in controlling infection. An experimental rat model is put in place to study the antibacterial properties of the induced membrane produced during the first stage of Masquelet. METHOD: Twenty-three-month-old wistar male rats are inoculated with a 0.5 mL solution of 10^8 CFU/mL MRSA over a critical fracture done on the right femur. Six weeks later, remaining 11 rats exhibiting signs of a chronic infection with a sinus tract and oozing pus along with radiological nonunion are used for a first stage Masquelet procedure. They are randomly divided into two groups with six rats having no local antibiotic in the cement mixture and five rats having 3 g of vancomycin mixed with gentamycin loaded cement. Six weeks later (twelve weeks from baseline), all eleven rats are euthanized and blood samples for C-reactive protein are withdrawn. The induced membrane is identified and resected along with bone fragments and sent for cultures and pathology. RESULTS: MRSA is isolated in the cultures of all six rats in the first group where no local antibiotic was added. Altered polymorphonuclears with abscess and pus are noted on four of six pathology samples. However in the second group where local antibiotics were added, three out of five rats exhibited eradication of MRSA (p = 0.034) and all samples did not exhibit clear infection signs on pathology. A pyo-epithelioid over a foreign body reaction is seen predominantly in this group demonstrating a regenerative process. DISCUSSION: The induced membrane does not have antimicrobial properties capable of overcoming an infected nonunion on its own. When local antibiotics were added during the first stage of the Masquelet procedure, new bone formation occurred indicating the need to control an infection in order for bone union to occur. CONCLUSION: Local antibiotics use in adjunction to extensive debridement is advisable during the first stage of a Masquelet procedure for an infected nonunion.

High mortality following distal femur fractures: a cohort study including three hundred and two distal femur fractures.

PURPOSE: What are the overall, 30-day, 6-month, and 1-year mortality rates following distal femur fractures? METHODS: Epidemiological cohort study. Retrospective reviews of charts and X-rays based on a search in the National Danish Health Registry. RESULTS: A total of 293 patients were treated for 302 distal femur fractures between 2005 and 2010. The mean age at the time of fracture was 44.0 years for males and 71.6 years for females. The overall mortality rates after a non-periprosthetic distal femur fracture at 30 days, six months, and one year were 5%, 15%, and 21%, respectively. The mortality rates for patients at > 60 years at 30 days, six months, and one year were 8%, 26%, and 35%, respectively. The mortality rates for patients at ≤ 60 years at 30 days, six months, and one year were 1%, 2%, and 3%, respectively. The overall mortality rates after a periprosthetic distal femur fracture at 30 days, six months, and one year were 10%, 15%, and 15%. Males were 2.6 (95% CI 1.01-6.86, P = 0.04) times more likely to die within the first year compared to women. Patients treated by conservative means shows a 2.8 (95% CI 1.41-5.54, P = 0.03) times increased likelihood of death within the first year compared to patients treated with surgery. CONCLUSIONS: The overall one year mortality rate was 21% for non-periprosthetic distal femur fractures and was elevated to 35% in patients older than 60 years. Patients presenting with a periprosthetic fracture showed a one year mortality rate of 15%.

Outcomes after implementation of an open fracture clinical pathway.

INTRODUCTION: Open fractures are associated with high rates of complication, morbidity and high economic costs. To improve outcomes, an open extremity fracture clinical pathway that protocolized surgical management and encouraged multidisciplinary collaboration was implemented in our institution. This study evaluates the clinical outcomes before and after the implementation of the pathway. METHODOLOGY: Retrospective review of open tibial and femur fractures covering the 2 year periods before and after pathway implementation was conducted. Patient demographics, fracture location, fixation methods and Gustilo-Anderson classification type were recorded. Primary outcomes include complications of wound infection, implant infection, delayed/non-union and flap failure occurring in a 1 year follow-up period. Secondary outcomes include length of hospital stay, time from emergency department (ED) entrance to first wound debridement, time from ED to flap coverage and total number of operations required. RESULTS: A total of 43 pre-pathway and 46 post-pathway patients were included in this study. There was a significant reduction in length of hospital stay, a 37.5% decrease from a median of 11.2 to 7 days after pathway implementation. There was also a significant decrease in the number of fractures fixed with external fixators from 47 to 26%. No significant differences were found for the other secondary variables. In a subgroup analysis of type III fractures, there was a significant decrease in length of hospital stay as well as the number of operations required. Median length of hospital stay decreased by 46.7% from 15 to 8 days and total number of operations decreased by 50% from a median of four operations to two operations. CONCLUSION: This study demonstrates that the implementation of an open extremity fracture clinical pathway significantly reduces the proportion of external fixation surgeries, length of hospital stay, and number of operations in patients with open tibial and femur fractures, without compromising complication rates.