Skin Antisepsis before Surgical Fixation of Extremity Fractures.

BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

Operative and Nonoperative Treatment of Humeral Shaft Fractures: A Cost-Effectiveness Analysis.

BACKGROUND: Decision-making with regard to the treatment of humeral shaft fractures remains under debate. The cost-effectiveness of these treatment options has yet to be established. This study aims to compare the cost-effectiveness of operative treatment with that of nonoperative treatment of humeral shaft fractures. METHODS: We developed a decision tree for treatment options. Surgical costs included the ambulatory surgical fee, physician fee, anesthesia fee, and, in the sensitivity analysis, lost wages during recovery. We used the Current Procedural Terminology codes from the American Board of Orthopaedic Surgery to determine physician fees via the U.S. Centers for Medicare & Medicaid Services database. The anesthesia fee was obtained from the national conversion factor and mean operative time for included procedures. We obtained data on mean wages from the U.S. Bureau of Labor and data on weeks missed from a similar study. We reported functional data via the Disabilities of the Arm, Shoulder and Hand (DASH) scores obtained from existing literature. We used rollback analysis and Monte Carlo simulation to determine the cost-effectiveness of each treatment option, presented in dollars per meaningful change in DASH score, utilizing a $50,000 willingness-to-pay (WTP) threshold. RESULTS: The cost per meaningful change in DASH score for operative treatment was $18,857.97 at the 6-month follow-up and $25,756.36 at the 1-year follow-up, by Monte Carlo simulation. Wage loss-inclusive models revealed values that fall even farther below the WTP threshold, making operative management the more cost-effective treatment option compared with nonoperative treatment in both settings. With an upward variation of the nonoperative union rate to 84.17% in the wage-exclusive model and 89.43% in the wage-inclusive model, nonoperative treatment instead became more cost-effective. CONCLUSIONS: Operative management was cost-effective at both 6 months and 1 year, compared with nonoperative treatment, in both models. Operative treatment was found to be even more cost-effective with loss of wages considered, suggesting that an earlier return to baseline function and, thus, return to work are important considerations in making operative treatment the more cost-effective option. LEVEL OF EVIDENCE: Economic and Decision Analysis Level III . See Instructions for Authors for a complete description of levels of evidence.

Artificial Intelligence in Orthopaedic Surgery: Can a Large Language Model "Write" a Believable Orthopaedic Journal Article?

ABSTRACT: ➢ Natural language processing with large language models is a subdivision of artificial intelligence (AI) that extracts meaning from text with use of linguistic rules, statistics, and machine learning to generate appropriate text responses. Its utilization in medicine and in the field of orthopaedic surgery is rapidly growing.➢ Large language models can be utilized in generating scientific manuscript texts of a publishable quality; however, they suffer from AI hallucinations, in which untruths or half-truths are stated with misleading confidence. Their use raises considerable concerns regarding the potential for research misconduct and for hallucinations to insert misinformation into the clinical literature.➢ Current editorial processes are insufficient for identifying the involvement of large language models in manuscripts. Academic publishing must adapt to encourage safe use of these tools by establishing clear guidelines for their use, which should be adopted across the orthopaedic literature, and by implementing additional steps in the editorial screening process to identify the use of these tools in submitted manuscripts.

Use of a Six-Item Modified Frailty Index to Predict 30-day Adverse Events, Readmission, and Mortality in Older Patients Undergoing Surgical Fixation of Lower Extremity, Pelvic, and Acetabular Fractures.

INTRODUCTION: This is a retrospective study evaluating the use of a new six-item modified frailty index (MF-6) to predict short-term outcomes of patients receiving surgery for lower extremity fractures. METHODS: Patients older than 65 years undergoing open reduction and internal fixation for lower extremity, pelvic, and acetabulum fractures were identified from the American College of Surgeons National Surgical Quality Improvement Program. The MF-6 was calculated by assigning one point for each of six common conditions. Multivariable analysis was used to compare patients with an MF-6 of <3 and ≥3. Outcome measures included complications, mortality, readmission, revision surgery, and length of stay. An area under the curve receiver operator analysis was conducted to compare the MF-6 with MF-5, an existing five-item frailty index. RESULTS: Nine thousand four hundred sixty-three patients were included. Patients with an MF-6 of ≥3 were at markedly higher risk of discharge destination other than home (Exp[B] = 2.09), mortality (Exp[B] = 2.48), major adverse events (Exp[B] = 2.16), and readmission (Exp[B] = 1.82). Receiver-operating curve analysis demonstrated an area under the curve of 0.65 for mortality, 0.62 for major adverse events, and 0.62 for discharge destination other than home, all of which outperformed the MF-5. DISCUSSION: The MF-6 was correlated with a 30-day postoperative incidence of infectious complications, readmission, and discharge destination. MF-6 scores can be used to risk-stratify patient populations as shifts to value-based care continue to develop.

Single versus dual incision approaches for dual plating of bicondylar tibial plateau fractures have comparable rates of deep infection and revision surgery.

OBJECTIVES: The use of one midline incision versus dual medial/lateral incisions for dual plating of bicondylar tibial plateau (BTP) fractures is controversial. This study aimed to compare rates of infection and secondary surgery in patients treated with dual plating for a BTP fracture using a single versus double incisions. DESIGN: Retrospective cohort study. SETTING: Two Level-1 trauma centers. PATIENTS/PARTICIPANTS: Patients > 18 years with a closed AO/OTA 41-C BTP fracture without compartment syndrome treated with a single midline or dual incision (lateral with medial or posteromedial) approach for dual plating. INTERVENTION: Dual plating through either a single anterior incision, or dual medial/lateral incisions. MAIN OUTCOME MEASUREMENTS: Rates of deep infection and reoperation were compared using Chi-square analysis (p-value of < 0.05). RESULTS AND CONCLUSIONS: In total 636 AO/OTA 41-C BTP fractures treated between 1/1/01 and 12/31/18 were identified and assessed. After exclusions for limited follow up, other techniques, open fracture and the need for fasciotomies, 346 patients were studied. Of these 254 had been treated with a single plate / single approach technique while 92 had been dual plated, 41 through a single anterior incision while 51 had dual plating through separate lateral and medial or posteromedial incisions. For these 92 fractures, there was no significant difference in the rate of deep infection (22.0% vs 23.5%, s=0.858) or reoperation (31.7% vs 31.4%, p=0.973) between the single and dual incision groups. Injuries that had been treated with single plating via a single incision had comparably lower rates of deep infection (10.2% vs. 22.8%, p=0.003) and reoperation (12.2% vs. 31.5%, p<0.001). There were no significant differences in any demographic parameters between patients undergoing single versus dual plating. Although retrospective, not randomized and subject to single surgeon bias these data suggest that these complications are more based on injury than the approach. LEVEL OF EVIDENCE: III.

Comparative Outcomes and Surgical Timing for Operative Fragility Hip Fracture Patients during the COVID-19 Pandemic: A Retrospective Cohort Study.

The COVID-19 pandemic had wide-reaching effects on healthcare delivery, including care for hip fractures, a common injury among older adults. This study characterized factors related to surgical timing and outcomes, length-of-stay, and discharge disposition among patients treated for operative hip fractures during the first wave of the COVID-19 pandemic, compared to historical controls. A retrospective, observational cohort study was conducted from 16 March-20 May 2020 with a consecutive series of 64 operative fragility hip fracture patients at three tertiary academic medical centers. Historical controls were matched based on sex, surgical procedure, age, and comorbidities. Primary outcomes included 30-day mortality and time-to-surgery. Secondary outcomes included 30-day postoperative complications, length-of-stay, discharge disposition, and time to obtain a COVID-19 test result. There was no difference in 30-day mortality, complication rates, length-of-stay, anesthesia type, or time-to-surgery, despite a mean time to obtain a final preoperative COVID-19 test result of 17.6 h in the study group. Notably, 23.8% of patients were discharged to home during the COVID-19 pandemic, compared to 4.8% among controls (p = 0.003). On average, patients received surgical care within 48 h of arrival during the COVID-19 pandemic. More patients were discharged to home rather than a facility with no change in complications, suggesting an opportunity for increased discharge to home.

A Systematic Review of the Management of Upper Extremity Orthopaedic Injuries in Epileptic Patients.

Background: During seizures, injury of the upper extremities may occur. Standardized guidelines are deficient for diagnosis and perioperative care. Methods: PubMed, Embase, Cochrane, Scopus, and Web of Science databases were systematically screened using predefined search terms. Results: Of the 59 patients included, 36 (61.0%) involved a posterior shoulder dislocation. Associated fractures were observed in 34 (57.6%) cases with surgical procedures performed in 30 (50.8%) patients. Functional outcomes were reported in 44 patients, with over half (23 of 44, [52.2%]) endorsing range of motion deficits. Conclusion: Standardized guidelines, to guarantee timely management of injury in post-seizure patients, are needed with a customized treatment approach that accommodates the various aspects of their condition.

Racial Differences in Orthopedic Trauma Surgery.

Racial discrepancies among patients in the United States undergoing orthopedic trauma surgery have not been investigated. Issues relating to socioeconomic status and access to care have played a role in the health outcomes of racial groups. In orthopedic surgery, recent joint arthroplasty literature has shown significant racial differences in the use of elective joint arthroplasty. Furthermore, studies also suggest increased rates of early complication in racial minority groups. In general, little information exists on the postoperative outcomes of racial minority groups in orthopedic surgery. We retrospectively queried the National Surgical Quality Improvement Program database to identify patients undergoing orthopedic trauma surgery between 2008 and 2016. Patients of all ages who underwent orthopedic trauma surgery were identified using Current Procedural Terminology codes. Patients classified as either Black or White were included in the study. Demographic data, comorbidities, and basic surgical data were compared between the groups. Adverse outcomes in the initial 30 days postoperative were also examined. Higher frequencies of deep wound infection (0.5% vs 0.3%, P=.002) were noted among Black patients, with decreased mortality (0.3% vs 0.6%, P=.004) and postoperative transfusion (2.7% vs 3.8%, P<.001) rates, compared with White patients. Clear differences exist in the demographic, surgical, and outcome data between Black and White patients undergoing orthopedic trauma surgery. More epidemiological studies are required to further investigate racial differences in orthopedic trauma surgery. [Orthopedics. 2022;45(2):71-76.].

Hematoma Formation After Hip Corticosteroid Injection in a Patient with Chronic Myelomonocytic Leukemia: A Case Report.

CASE: We present a 70-year-old woman with history of chronic myelomonocytic leukemia with a right thigh hematoma after a corticosteroid hip injection. Aspiration of the hematoma was attempted, but she developed a significant transfusion requirement with paresthesias in a lateral femoral cutaneous nerve distribution, prompting transfer. Imaging demonstrated no active extravasation, and she was managed conservatively. At 8-month follow-up, she had a persistent consolidated hematoma on the right side, and she subsequently died of complications of her cancer. CONCLUSION: This case demonstrates an unusual complication from a common nonoperative modality, as well as important coagulopathies that must be considered in patients with leukemia.

Is It Safe to Prep the External Fixator In Situ During Staged ORIF of Bicondylar Tibial Plateau Fractures? A Retrospective Comparative Cohort Study.

OBJECTIVES: To compare the risk of deep infection and unplanned reoperation after staged open reduction internal fixation (ORIF) of bicondylar tibial plateau (BTP) fractures whether elements of the temporizing external fixator were prepped into the surgical field or completely removed before definitive fixation. DESIGN: Retrospective comparative cohort study. SETTING: Two academic Level 1 trauma centers. PATIENTS/PARTICIPANTS: One hundred forty-seven OTA/AO 41-C (Schatzker 6) BTP fractures treated with a 2-stage protocol of acute spanning ex-fix followed by definitive ORIF between 2001 and 2018. INTERVENTION: Seventy-eight fractures had retained elements of the original ex-fix prepped in situ during surgery for definitive internal fixation, and 69 had the ex-fix construct completely removed before prepping and draping. MAIN OUTCOME MEASURES: Deep infection and unplanned reoperation. RESULTS: Among 147 patients treated with staged ORIF, the overall deep infection rate was 26.5% and the reoperation rate was 33.3%. There were high rates of deep infection (26.9% vs. 26.1%, P = 0.909) and unplanned reoperation (30.8% vs. 36.2%, P = 0.483) in both groups, but no difference whether the ex-fix was prepped in or completely removed. Within the retained ex-fix group, there was no difference in infection with retention of the entire ex-fix compared with only the ex-fix pins (28.1% vs. 26.1%, P = 0.842). CONCLUSIONS: We observed high complication rates in this cohort of OTA/AO 41C BTP fractures treated with staged ORIF, but prepping in the ex-fix did not lead to a significant increase in rates of infection or reoperation. This study provides the treating surgeon with clinical data about a common practice used to facilitate definitive fixation of unstable BTP fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparing Relative Value Units among Shoulder Arthroplasty, Hemiarthroplasty, and ORIF for Proximal Humerus Fractures in the Elderly: Which is Most Worth Your Time?

BACKGROUND: Relative value units (RVUs) are assigned to Current Procedural Technology (CPT) codes and give relative economic values to the services physicians provide. This study compared the RVU reimbursements for the surgical options of proximal humerus fractures in the elderly, which include arthroplasty (reverse [RSA] and total [TSA]), hemiarthroplasty (HA), and open reduction and internal fixation (ORIF). METHODS: Using the National Surgical Quality Improvement Program, a total of 1,437 patients of at least 65 years of age with proximal humerus fractures between 2008 and 2016 were identified. Of those, 259 underwent RSA/TSA (CPT code 23472), 418 underwent HA (CPT codes 23470 and 23616), and 760 underwent ORIF (CPT code 23615). Univariate analysis compared RVU per minute, reimbursement rate, and the average annual revenue across cohorts based on respective operative times. RESULTS: RSA/TSA generated a mean RVU per minute of 0.197 (SD 0.078; 95%CI [0.188, 0.207]), which was significantly greater than the mean RVU per minute for 23470 HA (0.156; SD 0.057; 95%CI [0.148, 0.163]), 23616 HA (0.166; SD 0.065; 95%CI [0.005, 0.156]), and ORIF (0.135; SD 0.048; 95%CI [0.132, 0.138]; P<0.001). This converted to respective reimbursement rates of $6.97/min (SD 2.78; 95%CI [6.63, 7.31]), $5.48/min (SD 2.05; 95%CI [5.22, 5.74]), $5.83/min (SD 2.28; 95%CI [5.49, 6.16]) and $4.74/min (SD 1.69; 95%CI [4.62, 4.87]). After extrapolation, respective average annual revenues were $580,386, $456,633, $475,077, and $395,608. CONCLUSION: RSA/TSA provides significantly greater reimbursement rates compared to HA and ORIF. Orthopaedic surgeons can use this information to optimize daily procedural cost-effectiveness in their practices.

A Culture Change in Geriatric Traumatology: Holistic and Patient-Tailored Care for Frail Patients with Fractures.

ABSTRACT: Medical decision-making for frail geriatric trauma patients is complex, especially toward the end of life. The goal of this paper is to review aspects of end-of-life decision-making, such as frailty, cognitive impairment, quality of life, goals of care, and palliative care. Additionally, we make recommendations for composing a patient-tailored treatment plan. In doing so, we seek to initiate the much-needed discussion regarding end-of-life care for frail geriatric patients.

Complications and Soft-Tissue Coverage After Complete Articular, Open Tibial Plafond Fractures.

OBJECTIVES: To evaluate the incidence of nonunion and wound complications after open, complete articular pilon fractures. Second, to study the effect that both timing of fixation and timing of flap coverage have on deep infection rates. DESIGN: Retrospective case series. SETTING: Three Academic Level 1 Trauma Centers. PATIENTS: One hundred sixty-one patients with open OTA/AO type 43C distal tibia fractures treated with open reduction internal fixation (ORIF) between 2002 and 2018. The mean (SD) age was 46 (14) years, 70% male, with median (interquartile range) follow-up of 2.1 (1.3-5.0) years (minimum 1 year). There were 133 (83%) type 3A and 28 (17%) type 3B open fractures. INTERVENTION: Fracture fixation: acute, primary (<24 hours) versus delayed, staged ORIF (>24 hours). Soft-tissue coverage: rotational or free flap. MAIN OUTCOME MEASUREMENT: Primary outcomes included deep infection and nonunion. Secondary outcomes included rates of soft-tissue coverage and reoperation. RESULTS: Acute fixation (<24 hours) was performed in 36 (22%) patients; 125 (78%) underwent delayed, staged fixation. Deep infection occurred in 27% patients and was associated with men (33% vs. 16%, P = 0.029), smoking (38% vs. 23%, P = 0.047), and type 3B fractures (39% vs. 25%, P = 0.046). Acute fixation of type 3A fractures demonstrated a higher rate of infection (38% vs. 20% P = 0.036) than delayed, staged fixation. In type 3B fractures, early flap coverage (<1 week) demonstrated a lower rate of infection (18% vs. 53%, P = 0.066) and 20% (vs. 43%) with a single-staged "fix and flap" procedure (P = 0.408). Nonunion occurred in 36 (22%) and was associated with deep infection (43% vs. 15%, P < 0.001). Fifteen (42%) were septic nonunions. Twenty-nine of the 36 (81%) nonunions achieved radiographic union after median (interquartile range) 27 (20-41) weeks and median (range) 1 (1-3) revision ORIF procedures. There was no difference in the rate of secondary union between septic and aseptic nonunions (85% vs. 86%, P = 1.00). There was a high rate of secondary procedures (47%): revision ORIF (17%), irrigation and debridement (15%), and removal of implants (11%). CONCLUSIONS: Complete articular, open pilon fractures are associated with a high rate of complications after ORIF. Early fixation carries a high risk of deep infection; however, early flap coverage for 3B fractures seems to play a protective role. We advocate for aggressive management including urgent surgical debridement and very early soft-tissue cover combined with definitive fixation during single procedure if possible. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Spontaneous iliacus haematoma with femoral nerve palsy: an appeal to involve surgical teams early.

We report the case of a 68-year-old man who was placed on heparin as bridge therapy and subsequently developed an iliacus haematoma with associated femoral nerve palsy. His team involved the orthopaedic surgery team in delayed fashion after his symptom onset. Due to his active medical conditions, he did not undergo surgical decompression of his haematoma until late into his hospital course. Unfortunately, this patient did not regain meaningful function from his femoral nerve deficit. We believe this case highlights the high index of suspicion necessary for making this diagnosis as well as the repercussions of an untimely decompression for this acute, compressive neuropathy. Although we are surgeons and this is a surgical case, we hope to publish this case in a medical journal to raise awareness that surgical decompression does have a role in this diagnosis and should ultimately be pursued early in its course for optimal patient benefit.

Perspective on optical imaging for functional assessment in musculoskeletal extremity trauma surgery.

SIGNIFICANCE: Extremity injury represents the leading cause of trauma hospitalizations among adults under the age of 65 years, and long-term impairments are often substantial. Restoring function depends, in large part, on bone and soft tissue healing. Thus, decisions around treatment strategy are based on assessment of the healing potential of injured bone and/or soft tissue. However, at the present, this assessment is based on subjective clinical clues and/or cadaveric studies without any objective measure. Optical imaging is an ideal method to solve several of these issues. AIM: The aim is to highlight the current challenges in assessing bone and tissue perfusion/viability and the potentially high impact applications for optical imaging in orthopaedic surgery. APPROACH: The prospective will review the current challenges faced by the orthopaedic surgeon and briefly discuss optical imaging tools that have been published. With this in mind, it will suggest key research areas that could be evolved to help make surgical assessments more objective and quantitative. RESULTS: Orthopaedic surgical procedures should benefit from incorporation of methods to measure functional blood perfusion or tissue metabolism. The types of measurements though can vary in the depth of tissue sampled, with some being quite superficial and others sensing several millimeters into the tissue. Most of these intrasurgical imaging tools represent an ideal way to improve surgical treatment of orthopaedic injuries due to their inherent point-of-care use and their compatibility with real-time management. CONCLUSION: While there are several optical measurements to directly measure bone function, the choice of tools can determine also the signal strength and depth of sampling. For orthopaedic surgery, real-time data regarding bone and tissue perfusion should lead to more effective patient-specific management of common orthopaedic conditions, requiring deeper penetrance commonly seen with indocyanine green imaging. This will lower morbidity and result in decreased variability associated with how these conditions are managed.

Risk factors for developing acute compartment syndrome in the pediatric population: a systematic review and meta-analysis.

PURPOSE: Acute compartment syndrome (ACS) is often difficult to diagnose in pediatric patients due to their erratic symptomatology. Therefore, it is of paramount importance to identify at-risk patients to facilitate a prompt diagnosis. This study aims to identify risk factors for the development of ACS in the pediatric population. METHODS: We included studies comprised of pediatric patients with traumatic ACS. We excluded studies evaluating compartment syndrome secondary to exertion, vascular insult, abdominal processes, burns, and snake bites. Heterogeneity was addressed by subgroup analysis, and whenever it remained significant, we utilized a random-effects meta-analysis for data pooling. The protocol has been registered at PROSPERO (ID = CRD42019126603). RESULTS: We included nine studies with 380,411 patients, of which 1144 patients were diagnosed with traumatic ACS. The average age was 10 years old, and 67% of patients were male. Factors that were significantly associated with ACS were: open radius/ulna fractures (OR 3.56 CI 1.52-8.33, p = 0.003), high-energy trauma (OR 3.51 CI 1.71-7.21, p = 0.001), humerus fractures occurring concurrently with forearm fractures (OR 3.49 CI 1.87-6.52, p < 0.001), open tibia fractures (OR 2.29 CI 1.47-3.55, p < 0.001), and male gender (OR 2.06 CI 1.70-2.51, p < 0.001). CONCLUSION: In the present study, open fractures, high-energy trauma, concurrent humerus and forearm fractures, and male gender significantly increased the risk of developing ACS in the pediatric population. Clinicians should raise their suspicion for ACS when one or multiple of these factors are present in the right clinical context. TYPE OF STUDY: Systematic review and meta-analysis. LEVEL OF EVIDENCE: III.

Mortality Risk Assessment of Total Knee Arthroplasty and Related Surgery After Percutaneous Coronary Intervention.

BACKGROUND: The optimal antiplatelet therapy (APT) treatment strategy after Coronary Artery Stenting (CAS) in non-cardiac surgery, such as total knee arthroplasty (TKA) or urgent TKA-related surgery remains unknown. METHODS: We built a decision tree model to examine the mortality outcomes of two alternative strategies for APT after CAS use in the perioperative period namely, continuous use and discontinuation. RESULTS: If surgery was performed in the first month after CAS placement, discontinuing APT led to an estimated 30-day post TKA mortality of 10.5%, compared to 1.0% in a strategy with continuous APT use. Mortality with both strategies decreased with longer intervals. CONCLUSION: Our model demonstrated that APT discontinuation in patients undergoing TKA or urgent TKA related surgery after CAS placement might lead to greater 30-day mortality up to one year.

Diagnosis and treatment of acute extremity compartment syndrome.

Acute compartment syndrome of the extremities is well known, but diagnosis can be challenging. Ineffective treatment can have devastating consequences, such as permanent dysaesthesia, ischaemic contractures, muscle dysfunction, loss of limb, and even loss of life. Despite many studies, there is no consensus about the way in which acute extremity compartment syndromes should be diagnosed. Many surgeons suggest continuous monitoring of intracompartmental pressure for all patients who have high-risk extremity injuries, whereas others suggest aggressive surgical intervention if acute compartment syndrome is even suspected. Although surgical fasciotomy might reduce intracompartmental pressure, this procedure also carries the risk of long-term complications. In this paper in The Lancet Series about emergency surgery we summarise the available data on acute extremity compartment syndrome of the upper and lower extremities in adults and children, discuss the underlying pathophysiology, and propose a clinical guideline based on the available data.

Complications of pelvic radiation in patients treated for gynecologic malignancies.

Radiation therapy is a critical treatment modality in the management of patients with gynecologic tumors. New highly conformal external-beam and brachytherapy techniques have led to important reductions in recurrence and patient morbidity and mortality. However, patients who receive pelvic radiation for gynecologic malignancies may experience a unique constellation of toxicity because of the anatomic locations, combination with concurrent chemotherapy and/or surgery, as well as potential surgical interventions. Although side effects are often categorized into acute versus late toxicities, several late toxicities represent continuation and evolution of the same pathologic process. Comorbidities and radiation dose can significantly increase the risk of morbidity. Current understanding of the incidence of various morbidities in patients treated with current radiation techniques for gynecologic malignancies, the impact of chemotherapy and surgery, treatment options for those effects, and future areas of research are highlighted.