Adults with paternal UPD14 causing Kagami-Ogata syndrome: Case report and review of the literature.

Kagami-Ogata syndrome (KOS) is a clinically recognizable syndrome in the neonatal period. It is characterized by specific skeletal anomalies and facial dysmorphisms. It is typically caused by paternal uniparental disomy of chromosome 14, while epimutations and microdeletions are less commonly reported causes. In the pediatric setting, KOS is a well delineated syndrome. However, there is a dearth of literature describing the natural history of the condition in adults. Herein, we describe a 35-year-old man, the first adult with KOS reported due to paternal uniparental disomy 14, and review reports of KOS in other affected adults. This highlights the variability in neurocognitive phenotypes, the presence of connective tissue abnormalities, and the uncertainties around long-term cancer risk.

Circumventing Acute Compartment Syndrome: Outcomes from a Cadaver-based Course in Fasciotomy Procedural Skills.

Acute compartment syndrome (ACS) represents a surgical emergency requiring effective, complete fasciotomy. The purpose of this study is to evaluate cadaver-based training on the ability of practicing general surgeons to effectively perform upper extremity, thigh, and leg fasciotomies. One hundred seventeen general surgeons underwent a 2-day, cadaver-based course with formative and summative assessments based on validated scoring tools. Overall performance and critical item scores were recorded and compared utilizing analysis of variance with repeated measures and eta-squared values to evaluate effect size. For all three procedures, post-training scores were significantly improved when compared with pre-training scores (p < 0.001). Mean pre-training score for lower leg fasciotomy met the standard for competent performance of the procedure (total score > 80), whereas neither thigh nor upper extremity performance scores met this standard before training. This 2-day, cadaver-based course improves the ability of practicing general surgeons to effectively and independently perform upper extremity, thigh, and lower leg fasciotomies. (Journal of Surgical Orthopaedic Advances 32(4):238-241, 2023).

No Difference in Risk of Implant Removal Between Orthogonal Mini-fragment and Single Small-fragment Plating of Midshaft Clavicle Fractures in a Military Population: A Preliminary Study.

BACKGROUND: Clavicle fractures are common, especially in military personnel. A persistent problem of open reduction and internal fixation (ORIF) of the clavicle is the high percentage of symptomatic implants needing removal. Prominent implants can lead to discomfort in military service members performing activities such as carrying rucksacks and firing high-caliber weapons, potentially resulting in a high removal of implant rate. Alternative approaches to plate fixation may mitigate this, but to our knowledge, only limited evidence is available comparing various plate-fixation approaches. QUESTIONS/PURPOSES: In a military population, we asked (1) Is there a difference in implant removal rates after midshaft clavicle fixation using orthogonal plating with 2.7-mm reconstruction plates versus a single 3.5-mm locking compression plate? (2) What complications are associated with each fixation approach? (3) Is there a difference in surgical time between the approaches? METHODS: Between January 2010 and May 2015, three surgeons performed 99 ORIF procedures of midshaft clavicle fractures, always using a single small-fragment plate, and one surgeon performed 34 procedures, always using two mini-fragment plates with an orthogonal plating construct. Of those, 89 (90%) in the small-fragment plating group were available for analysis in this retrospective study and 33 (97%) were available for analysis in the mini-fragment plating group, both groups with a minimum of 2 years of followup. There were no between-group differences in terms of gender, tobacco use, injured side, hand dominance, 100% displacement, comminution, shortening, and active-duty status. We analyzed the proportion of patients who had their plates removed for any complications recorded in their charts. Assessment bias for indications for symptomatic removal of implant was minimized as there was always another fellowship-trained trauma surgeon at our institution available for a second opinion if the operative surgeon did not agree with a patient request for implant removal. A posthoc power calculation indicated that with the numbers available, we had 80% power to detect a between-group difference in implant removal proportion of 14.5% at the p < 0.05 level. RESULTS: We found no difference between the small-fragment plating group and the mini-fragment group in the frequency of plate removal (9% [8 of 89] versus 0% [0 of 33]; odds ratio, 3.38 [95% confidence interval 0.41 to 27.68]; p = 0.11); a worst-case analysis that assumed all patients lost to follow-up underwent plate removal did not change this no-difference finding. All cases of implant removal were performed secondary to a symptomatic implant. With the numbers available, there were no differences between the two groups in nonunion, delayed union, infection, or other complications. There was a longer mean operative time in the mini-fragment group than in the small-fragment group (173.7 minutes versus 118.7 minutes; mean difference, 55 minutes [95% CI 38.71 to 71.23]; p < .001). Our overall implant removal percentage for the two groups combined was 6.6% (8 of 122). CONCLUSIONS: Our study was underpowered to show differences in implant removal but may serve as a pilot for larger randomized controlled trials or multi-institutional studies on this topic. Although there was increased operative time to insert two plates, there was no difference in overall complications. LEVEL OF EVIDENCE: Level III, therapeutic study.

TAF1 Variants Are Associated with Dysmorphic Features, Intellectual Disability, and Neurological Manifestations.

We describe an X-linked genetic syndrome associated with mutations in TAF1 and manifesting with global developmental delay, intellectual disability (ID), characteristic facial dysmorphology, generalized hypotonia, and variable neurologic features, all in male individuals. Simultaneous studies using diverse strategies led to the identification of nine families with overlapping clinical presentations and affected by de novo or maternally inherited single-nucleotide changes. Two additional families harboring large duplications involving TAF1 were also found to share phenotypic overlap with the probands harboring single-nucleotide changes, but they also demonstrated a severe neurodegeneration phenotype. Functional analysis with RNA-seq for one of the families suggested that the phenotype is associated with downregulation of a set of genes notably enriched with genes regulated by E-box proteins. In addition, knockdown and mutant studies of this gene in zebrafish have shown a quantifiable, albeit small, effect on a neuronal phenotype. Our results suggest that mutations in TAF1 play a critical role in the development of this X-linked ID syndrome.

Comminuted olecranon fractures: biomechanical testing of locked versus minifragment non-locked plate fixation.

INTRODUCTION: Open reduction and internal fixation has long been accepted as optimal treatment for displaced olecranon fractures based on poor results seen with conservative management. With the presence of comminution, tension-band wiring constructs are contraindicated due to tendency to compress through fragments, thereby shortening the articular segment. Therefore, plate fixation is typically employed. Our hypothesis was that in a comminuted fracture model, 2.7 mm reconstruction plating without locking screws will perform equally to 3.5 mm locked plating in terms of fracture displacement and rotation (shear). MATERIALS AND METHODS: A three-part comminuted olecranon fracture pattern was created in nine matched pairs of cadaveric specimen using an oscillating saw in standardized, reproducible fashion. Each matched pair was then randomized to receive either 2.7 mm reconstruction plating or 3.5 mm proximal ulna locked plating. Random allocation software was used to assign the 2.7 mm plate construct to either the right or left side of each pair with the contralateral receiving the 3.5 mm plate construct. Specimens were cyclically loaded simulating passive range of motion exercises commonly performed during rehabilitation. Displacement and rotation in relation to the long axis of the ulna were measured through motion capture. Fragment gapping and rotation was quantified following 100 cycles at 10 N and again following 100 cycles at 500 N. RESULTS: No significant differences were detected between the 2.7 and 3.5 mm plates in fracture rotation or gapping following loads at 10 N (0.5° and 0.7°; 0.6 and 1.2 mm; respectively; p > 0.05) or 500 N (2.3° and 1.6°; 3.8 and 3.1 mm; respectively; p > 0.05) loading. Fragment rotation and gapping were positively correlated within each plate construct (R 2 > 0.445; p < 0.05). CONCLUSIONS: 2.7 mm plating is an alternative to 3.5 mm locked plating with decreased plate prominence without significantly sacrificing displacement and rotational control. This is beneficial in fracture patterns where the traditional dorsal plating does not offer optimal screw trajectory.

Maternal 15q11.2-q13.1 duplication syndrome-associated psychosis and mania: a new case and review of the literature.

Maternal 15q11.2-q13.1 duplication syndrome is associated with a variety of developmental and neuropsychiatric abnormalities. Although schizophrenia-like presentations have been reported, details pertaining to the nature of the corresponding psychotic symptoms and their response to treatment have only been described in a few cases, and no reviews summarizing the literature currently exist. As such, we describe a new case of 15q11.2-q13.1 duplication syndrome-associated schizoaffective disorder and also performed a systematic review of the literature. Our patient's presentation is somewhat unique as she experienced visual hallucinations in the absence of auditory hallucinations. This is also the first report to describe full symptomatic remission in response to relatively low-dose atypical antipsychotic therapy.

Quantitative Analysis of Condition-based Limited Duty Duration of Musculoskeletal Conditions.

INTRODUCTION: Musculoskeletal injuries affect nearly a million service members annually within the DoD, ultimately costing the U.S. Military half a billion dollars in direct patient costs and a significant loss to fleet readiness as many members are assigned days on limited duty (LIMDU) until they are deemed medically fit to return to duty (RTD). The new approach implemented by Navy Medicine in 2022, called "condition-based LIMDU," aims to drastically impact the time in which Sailors and Marines spend under a provider's care by assigning LIMDU days based on a standardized set of guidelines. This study provides a quantitative analysis on LIMDU duration, before and after implementation of the new condition-based LIMDU paradigm, to increase the understanding on the effectiveness and impact to fleet readiness and to assess the accuracy of suggested patient outcome timelines. MATERIALS AND METHODS: De-identified and aggregated data were obtained from the Naval Medical Forces Atlantic's (NMFL) LIMDU Sailor and Marine Readiness Tracker System (SMART) program for all active duty military patients with ICD-10 code for musculoskeletal conditions. Only closed LIMDU cases in which active duty patients were given a final status of RTD were included. This study analyzed top musculoskeletal ICD-10 codes, optimum period (weeks), maximum period (weeks), and average days on LIMDU assigned at NMFL centers (medical and non-medical) for fiscal years 2021 (FY21) and 2022 (FY22). As well as descriptive statistics, t-test analysis was used to test if there was a difference between FY21 and FY22 and at what point the difference was no longer significant. Critical value method was then used to compare the top five most common musculoskeletal injuries to determine the accuracy of recommended LIMDU days to actual average assigned LIMDU per injury type. A color-coded compliance chart was created based on the results. RESULTS: The results showed that for RTD population, the implementation of condition-based LIMDU significantly decreased average days assigned on LIMDU by 33%. In fact, there is a 35-day (5-week) difference before we can confidently say that the difference between FY21 and FY22 is no longer statistically significant. This significant decrease in LIMDU days, before and after implementation, is a trend consistent at both medical and non-medical NMFL centers; however, medical centers reported significantly more assigned LIMDU days for both years. The five most common injuries of FY21 and FY22 were low back pain, pain in shoulder, pain in hip, pain in knee, and pain in ankle. Before implementation, all five of these injury types far exceeded the recommended amount of LIMDU days. With the new condition-based LIMDU paradigm, the average assigned LIMDU days for pain in hip, pain in knee, and pain in ankle were all found to be in compliance with the recommended LIMDU days within a 99% confidence level. CONCLUSIONS: The new condition-based LIMDU paradigm is successful in its aim to improve fleet readiness by returning Sailors and Marines to full duty status significantly faster. Regular assessment of ICD-10 diagnosis codes and update to recommended LIMDU assignment timelines should be conducted to maximize the effectiveness and accuracy for all medical conditions.

Detection of Traumatic Ankle Arthrotomies: Computed Tomography Scan Versus Saline Load Test.

OBJECTIVE: Periarticular wounds present a common diagnostic dilemma for emergency providers and orthopedic surgeons because traumatic arthrotomies (TA) often necessitate different management from superficial soft tissue wounds. Historically, TA have been diagnosed with the saline load test (SLT). Computed tomography (CT) scan has been studied as an alternative to SLT in diagnosing TA in several joints, but there are limited data specifically pertaining to the ankle. This study aimed to compare the ability of a CT scan to identify an ankle TA versus a traditional SLT. The hypothesis was that there would be no significant difference between a CT scan and SLT in diagnosing ankle TA in a cadaveric model. METHODS: This cadaveric study used 10 thawed fresh-frozen cadaveric ankles. A baseline CT scan was performed to ensure no intra-articular air existed before simulated TA. After the baseline CT, a 1 cm TA was created in the anterolateral arthroscopy portal site location. The ankles then underwent a postarthrotomy CT scan to evaluate for the presence of intra-articular air. After the CT scan, a 30 mL SLT was performed using the anteromedial portal site location. RESULTS: After arthrotomy, intra-articular air was visualized in 7 of 10 cadavers in the postarthrotomy CT scan. All the ankles had fluid extravasation during the SLT with <10 mL of saline. The sensitivity of the SLT for TA was 100% versus 70% for the CT scan. CONCLUSIONS: The SLT was more sensitive in diagnosing 1-cm ankle TA than a CT scan in a cadaveric model.

Biomechanical Analysis of Combined Medial Calcar and Lateral Locked Plating Versus Isolated Lateral Locked Plating of Proximal Humerus Fractures.

OBJECTIVE: Medial calcar buttress plating combined with lateral locked plating is biomechanically tested against isolated lateral locked plating in synthetic humeri models for the treatment of proximal humerus fractures. METHODS: Proximal humerus fractures (OTA/AO type 11-A2.1) were manufactured in 10 pairs of Sawbones humeri models (Sawbones, Pacific Research Laboratories, Vashon Island, WA). Specimen were randomly assigned and instrumented with either medial calcar buttress plating combined with lateral locked plating (CP) or isolated lateral locked plating (LP). Nondestructive torsional and axial load tests were performed to evaluate construct stiffness. Large-cycle axial tests were conducted followed by destructive ramp-to-failure tests. Cyclic stiffness was compared in both nondestructive and ultimate failure loads. Failure displacement was recorded and compared between groups. RESULTS: The addition of medial calcar buttress plating to lateral locked plating constructs significantly increased the axial ( P < 0.01) and torsional ( P < 0.01) stiffness of the construct compared with isolated lateral locked plating by 95.56% and 37.46%, respectively. All models demonstrated greater axial stiffness ( P < 0.01) after 5000 cycles of axial compression, not dependent on the fixation method. During destructive testing, the CP construct withstood 45.35% larger load ( P < 0.01) and congruently exhibited 58% less humeral head displacement ( P = 0.02) before failure when compared with the LP construct. CONCLUSION: This study demonstrates the biomechanical superiority of medial calcar buttress plating when combined with lateral locked plating as compared with isolated lateral locked plating of OTA/AO type 11-A2.1 proximal humerus in synthetic humeri models.

Clinical Characteristics of the 2019 Eastern Equine Encephalitis Outbreak in Michigan.

Background: Eastern equine encephalitis virus is a mosquito-borne alphavirus responsible for unpredictable outbreaks of severe neurologic disease in animals and humans. While most human infections are asymptomatic or clinically nonspecific, a minority of patients develops encephalitic disease, a devastating illness with a mortality rate of ≥30%. No treatments are known to be effective. Eastern equine encephalitis virus infection is rare in the United States, with an annual average nationwide incidence of 7 cases between 2009 and 2018. However, in 2019, 38 cases were confirmed nationwide, including 10 in Michigan. Methods: Data from 8 cases identified by a regional network of physicians in southwest Michigan were abstracted from clinical records. Clinical imaging and histopathology were aggregated and reviewed. Results: Patients were predominantly older adults (median age, 64 years), and all were male. Results of initial arboviral cerebrospinal fluid serology were frequently negative, and diagnosis was not made until a median of 24.5 days (range, 13-38 days) after presentation, despite prompt lumbar punctures in all patients. Imaging findings were dynamic and heterogeneous, with abnormalities of the thalamus and/or basal ganglia, and prominent pons and midbrain abnormalities were displayed in 1 patient. Six patients died, 1 survived the acute illness with severe neurologic sequelae, and 1 recovered with mild sequelae. A limited postmortem examination revealed diffuse meningoencephalitis, neuronophagia, and focal vascular necrosis. Conclusions: Eastern equine encephalitis is a frequently fatal condition whose diagnosis is often delayed, and for which no effective treatments are known. Improved diagnostics are needed to facilitate patient care and encourage the development of treatments.

The location of medial patellofemoral ligament injury in adolescents and children.

BACKGROUND: The location of medial patellofemoral ligament (MPFL) tears has been well documented in the adult population, with most occurring at the insertion of the ligament on the adductor tubercle. It is not clear whether a difference exists in the pediatric and adolescent populations. The location of the injury has implications for treatment recommendations and planning surgical approaches. The purpose of this study is to determine whether the location of MPFL injury differs among the adult and younger populations. Our hypothesis is that the location of MPFL tears in adolescents and children is not predominantly at the adductor tubercle. METHOD: At our institution, we retrospectively reviewed 113 children aged 5 to 17, who were surgically treated for a patellar dislocation. All patients had confirmation of a patellar dislocation or severe subluxation. Imaging studies, clinic notes, and operative notes were used to determine the location of the MPFL injury. RESULTS: Proportion of MPFL injuries found intraoperatively at the adductor tubercle was larger than 0.5 (z test=2.97). Percentage of MPFL tears at the adductor tubercle was 73% of the cases studied. CONCLUSIONS: The location of MPFL injuries found intraoperatively at the adductor tubercle was 73% in our series. This is slightly lower than MPFL tear location in the adult population, which has been reported to be between 80% and 100%. Our hypothesis that the location of MPFL tears in adolescents and children is not predominantly at the adductor tubercle was proven false. This study has clinical applications for treatment recommendations and planning surgical approaches for the pediatric patient with a tear of the MPFL. LEVEL OF EVIDENCE: Level II-prognostic.

Traumatic bilateral testicular dislocation associated with an anterior posterior compression fracture of the pelvis: a case report.

Traumatic dislocation of a single testicle is an exceedingly rare event and bilateral dislocation is even less common. Traumatic testicular dislocation occurs by the mechanism of direct pressure exerted on the scrotum. Motorcycle collisions are the most frequent causative mechanism, usually related to deceleration straddle injuries. Since traumatic testicular dislocation is associated with other severe injuries, it is usually a late finding, leading to delayed diagnosis and treatment. This report describes a rare case of a patient involved in a motorcycle crash who sustained bilateral testicular dislocation associated with an anterior posterior compression pelvic fracture. To date, there are no reported cases involving management of bilateral testicular dislocation discovered during open reduction and internal fixation of the pelvis. Because the orthopaedic traumatologist may be the first to assess patients with pelvic fracture requiring surgery, the authors feel it is important to raise awareness of this injury.

Submuscular locked plating of pediatric femur fractures.

Recent advances in plating technology for the pediatric femur fracture have demonstrated early mobilization of the extremity and early weight bearing. Submuscular techniques allow for minimal soft tissue disruption and provide a theoretical healing advantage. This article presents results of the treatment of pediatric femur fractures using a locked submuscular bridge plating technique. The authors reviewed 16 patients between 6 and 12 years of age who sustained a femoral shaft fracture treated with minimally invasive submuscular locked plating. Patients were followed for an average of 25 months and made full weight bearing within 6 weeks of surgery. All patients achieved radiographic and clinical union with an average time of 2.6 months. Range of motion of the knee and hip were equivalent to the contralateral extremity at 2.1 months. Average time of hardware removal was 11 months. Benefits of locked plating of pediatric femur fractures include high union rates, early weight bearing, early recovery of range of motion, and minimal complications.

Efficacy of hydrosurgical debridement and nanocrystalline silver dressings for infection prevention in type II and III open injuries.

The aim of this study was to retrospectively evaluate the clinical and culture-positive infection rates of open Gustilo/Anderson type II and III fractures using a protocol nanocrystalline silver wound dressing and hydrosurgical debridement. Retrospective case series through chart review on all type II and III open fractures were treated using a novel protocol from December 2005 to March 2008 (N = 17). All Gustilo/Anderson grade II and III open fractures were treated with a novel protocol at a Level I trauma centre. Open Gustilo/Anderson grade II and III fractures were acutely stabilised in the trauma centre/emergency department, while a nanocrystalline silver dressing was placed within the wound. Debridement using a hydrosurgical scalpel and gravity irrigation was performed within 6-8 hours of injury. Cultures were obtained prior to definitive fixation. The primary outcome measurements were positive cultures and clinical infection rates. Seventeen patients met inclusion criteria. Mean age (33·5) and injury severity score (12·7) were gathered. There were 4 grade II open fractures (23·5%), 11 grade IIIA (64·7%) and 2 grade IIIB open fractures (11·8%). The mean time to intravenous antibiotics was 61·5 minutes. The mean time to initial debridement/irrigation was 222·1 minutes. The average number of surgical procedures was 2·35 with a mean length of stay of 11·8 days. Six patients developed positive cultures from the traumatic wounds, five were contaminants. One clinical infection was found (methicillin-resistant Staphylococcus aureus). The overall clinical infection rate in this series was 5·9% (1/17). The only infection was in a Gustilo/Anderson grade II fracture. There were no infections in the more high-energy Gustilo/Anderson grade IIIA and IIIB fractures compared with the Gustilo/Anderson control of 4-42%. We conclude that this novel protocol for open-fracture treatment is a promising intervention. A further prospective randomised clinical study is warranted.

Early Advanced Weight-Bearing After Periarticular Fractures: A Randomized Trial Comparing Antigravity Treadmill Therapy Versus Standard of Care.

SUMMARY: In current clinical practice, weight-bearing is typically restricted for up to 12 weeks after definitive fixation of lower extremity periarticular fractures. However, muscle atrophy resulting from restricting weight-bearing has a deleterious effect on bone healing and overall limb function. Antigravity treadmill therapy may improve recovery by allowing patients to safely load the limb during therapy, thereby reducing the negative consequences of prolonged non-weight-bearing while avoiding complications associated with premature return to full weight-bearing. This article describes a multicenter randomized controlled trial comparing outcomes after a 10-week antigravity treadmill therapy program versus standard of care in adult patients with periarticular fractures of the knee and distal tibia. The primary hypothesis is that, compared with patients receiving standard of care, patients receiving antigravity treadmill therapy will report better function 6 months after definitive treatment.

Comparing medical cannabis use in 5 US states: a retrospective database study.

BACKGROUND: US states have been adopting their own medical cannabis laws since 1996. There is substantial variability in the medical cannabis programs between states, and these differences have not been thoroughly investigated in the literature. The objective of the study was to compare medical cannabis patient characteristics across five states to identify differences potentially caused by differing policies surrounding condition eligibility. METHODS: We conducted secondary analyses following a retrospective study of a registry database with data from 33 medical cannabis evaluation clinics in the US, owned and operated by CB2 Insights. This study narrowed the dataset to include patients from five states with the largest samples: Massachusetts (n = 27,892), Colorado (n = 16,434), Maine (n = 4591), Connecticut (n = 2643), and Maryland (n = 2403) to conduct an in-depth study of the characteristics of patients accessing medical cannabis in these states, including analysis of variance to compare average ages and number of conditions and chi-squared tests to compare proportions of patient characteristics between states. RESULTS: Average ages varied between the states, with the youngest average in Connecticut (42.2) and the oldest in Massachusetts (47.0). Males represented approximately 60% of the patients with data on gender in each state. The majority of patients in each state had cannabis experience prior to seeking medical certification. Primary medical conditions varied for each state, with chronic pain, anxiety, and back and neck problems topping the list in varying orders for Massachusetts, Maine, and Maryland. Colorado had 78.7% of patients report chronic pain as their primary condition, and 70.4% of patients in Connecticut reported post-traumatic stress disorder as their primary medical condition. CONCLUSION: This study demonstrated the significant impact that policy has on patients' access to medical cannabis in Massachusetts, Colorado, Maine, Connecticut, and Maryland utilizing real-world data. It highlights how qualifications differ between the five states and brings into question the routes through which patients in states with stricter regulations surrounding eligible conditions choose to seek treatment with cannabis. These patients may turn to alternative treatments, or to the illicit or recreational cannabis markets, where permitted.

An Assessment of Randomized Controlled Trial Quality in The Journal of Bone & Joint Surgery: Update from 2001 to 2013.

BACKGROUND: The quality of reporting of randomized controlled trials (RCTs) published in The Journal of Bone & Joint Surgery (JBJS) from 1988 to 2000 was previously analyzed. The purpose of this current study was to analyze the quality of reporting of RCTs published in JBJS from 2001 to 2013 to identify trends over time and potential areas of improvement for future clinical trials. METHODS: A manual search of the JBJS database identified RCTs published between January 2001 and December 2013. Quality assessments, using the Detsky quality-of-reporting index (Detsky score), a modified Cochrane risk-of-bias tool, and abstraction of relevant data identifying predictors of quality, were conducted. RESULTS: A total of 5,780 publications were identified in JBJS from 2001 to 2013, with 285 RCTs (4.9%), representing an increase from the prior 13-year period. The overall mean transformed Detsky score (and standard error) increased significantly (p < 0.001) from 68.1% ± 1.67% to 76.24% ± 0.72%. The percentage of multicenter RCTs decreased from 67% to 31%. The percentage of positive trials also decreased from 80% to 50.5%, as did the mean sample size (212 to 166). Regression analysis indicated that trials with an epidemiologist as the first author and nonsurgical trials were significantly associated (p = 0.001) with a higher overall trial quality score. The categories of the lowest mean methodology scores were randomization and concealment, eligibility criteria, and reasons for patient exclusion, as identified with the Detsky score, and patient and assessor blinding, as identified with the risk-of-bias assessment. CONCLUSIONS: The quantity and quality of published RCTs in JBJS have increased in the 2001 to 2013 time period compared with the previous time period. Although these improvements are encouraging, trends to smaller, single-center trials were also observed. To efficiently determine the efficacy of orthopaedic treatments and limit bias, high-quality randomized trials of appropriate sample size and rigorous design are needed.

Early Revision Surgery for Tibial Plateau Non-union and Mal-union.

BACKGROUND: Although relatively rare, non-unions and mal-unions of tibial plateau fractures present significant challenges for the orthopedic surgeon. With careful pre-operative planning, tibial plateau mal-union or non-union revision surgery with intra-articular and varus opening osteotomies can provides good functional results when performed early (within 1 year) after primary surgical procedure. QUESTIONS/PURPOSES: We present our treatment algorithm for approaching and treating non-union or mal-union of tibial plateau fractures. Our aim is to give surgeons treating these difficult injuries an overview of the pertinent literature as well as describe the challenges and pitfalls we have experienced when treating non-union or mal-union of tibial plateau fractures. METHODS: Using two case examples from our institution, one for mal-union and one for mal-reduction, we describe our treatment algorithm and surgical technique for managing these difficult injuries. We also provide a brief literature review outlining relevant studies and summarizing outcomes for similar injuries. A systematic literature review was conducted with the aim of determining the methods and outcomes commonly reported in the literature regarding revision surgery following tibial plateau non-union or mal-union. Due to the nature of revision surgery, there are no long-term randomized trials dealing with outcomes, but rather several smaller case series exist from which larger conclusions have to be drawn. RESULTS: To date, we have successfully treated approximately 35 patients with this technique, and clinical follow-up continues to show good functional outcomes with reduced pain and little radiographic evidence of arthritic changes. Restoring long leg alignment, anatomic reduction of the articular surface, and achieving stable internal fixation are paramount in achieving the best long-term outcome. Due to the shallow soft tissue envelope around the proximal tibia, and the tendency for these fractures to fall into progressive valgus collapse, these problems can seem intimidating and complex. However, with well-planned surgery and meticulous surgical technique, reliable healing can be achieved. CONCLUSION: By outlining our method, we hope to provide other surgeons with an algorithm to guide clinical and operative decision making. These difficult injuries can be daunting to treat, but if performed before the onset of severe degenerative arthritis, early revision surgery, as we describe, can be a viable alternative to total knee arthroplasty, particularly in younger, more active patients.

Reporting of planned statistical methods in published surgical randomised trial protocols: a protocol for a methodological systematic review.

INTRODUCTION: Poor reporting can lead to inadequate presentation of data, confusion regarding research methodology used, selective reporting of results, and other misinformation regarding health research. One of the most recent attempts to improve quality of reporting comes from the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) Group, which makes recommendations for the reporting of protocols. In this report, we present a protocol for a systematic review of published surgical randomised controlled trial (RCT) protocols, with the purpose of assessing the reporting quality and completeness of the statistical aspects. METHODS: We will include all published protocols of randomised trials that investigate surgical interventions. We will search MEDLINE, EMBASE, and CENTRAL for relevant studies. Author pairs will independently review all titles, abstracts, and full texts identified by the literature search, and extract data using a structured data extraction form. We will extract the following: year of publication, country, sample size, description of study population, description of intervention and control, primary outcome, important methodological qualities, and quality of reporting of planned statistical methods based on the SPIRIT guidelines. ETHICS AND DISSEMINATION: The results of this review will demonstrate the quality of statistical reporting of published surgical RCT protocols. This knowledge will inform recommendations to surgeons, researchers, journal editors and peer reviewers, and other knowledge users that focus on common deficiencies in reporting and how to rectify them. Ethics approval for this study is not required. We will disseminate the results of this review in peer-reviewed publications and conference presentations, and at a doctoral independent study of oral defence.

Debridement and Irrigation: Evolution and Current Recommendations.

Debridement is an integral step in the orthopaedic management of traumatic wounds, from open soft tissue injuries and routine open fracture care to the management of extensive high-energy blast injuries. While the necessity of debridement has been well established, the level of energy and degree of contamination of blast wounds encountered in recent armed conflict has offered a challenge and a new opportunity for military surgeons to revisit the most recent literature to guide our practice with the best evidence currently available. While the core tenants of removing the nonviable tissue and preserving the viable to maintain the best functional outcome have not changed, new wound care therapies and advances in prosthetics and salvage techniques and the ability to rapidly evacuate casualties have changed the approach to care provided on the front lines. This paper seeks to review the core principles of debridement and guide treatment using evidence-based methods that can be applied to contaminated open injuries on the battlefront and disaster and intentional violence injuries abroad and at home.