The Effect of Resident Involvement in Hip Fracture Surgery: An Analysis of a Single Institution Before and After the Addition of an Orthopaedic Surgical Residency.

INTRODUCTION: Hip fractures are common injuries that are associated with serious morbidity/mortality in the elderly and represent a substantial financial burden to healthcare systems. Previous studies demonstrated that resident involvement in orthopaedic surgeries is associated with increased surgical time and cost, with equivocal or worse outcomes. This study evaluated outcomes of hip fracture surgery at one institution, before and after the introduction of an orthopaedic residency program. METHODS: A retrospective chart review divided patients who underwent hip fracture surgery between January 2015 and January 2018 into two groups based on resident involvement. Outcomes including surgical time, length of stay (LOS), readmission rate, and direct/indirect costs were compared as were the American Society of Anesthesiologists physical status score and procedure conducted. RESULTS: Six hundred sixty-two hip fracture surgeries were performed in 36 months. Residents were engaged in 303 cases (45.8%) with no notable differences in the two groups regarding American Society of Anesthesiologists score, procedure conducted, or readmission rate. With resident involvement, surgical time was significantly longer (91.2 versus 78.9 minutes, P -value = 0.004), whereas LOS was significantly shorter (5.2 versus 5.6 days, P -value = 0.003). Finally, there were significant reductions in direct costs (8% reduction; P < 0.001) and OR implant costs (12% reduction; P < 0.001), but significant increase in indirect costs (7% increase; P < 0.001). DISCUSSION: Surgical experience is critical in orthopaedic training. There are concerns regarding potential negative effects of resident involvement on surgical outcomes and healthcare costs. While resident involvement was associated with slightly increased surgical times and indirect costs, it also led to decreased LOS and direct costs. We believe this is the first study to compare patient outcomes at one institution before and after resident involvement. Our findings demonstrated, compared with attendings alone, resident involvement resulted in an overall improvement rather than compromise in patient care.

Relation of mobilization after hip fractures on day of surgery to length of stay.

This study examined whether evaluation by physical therapy on the day of surgery impacts length of stay in patients with hip fractures. A total of 528 adult patients with hip fracture requiring surgery were prospectively included in the study over a 22-month period. The median length of stay of mobilized patients was 4.0 days, vs 5.0 days in nonmobilized patients (P = 0.0158). Of the 259 mobilized patients, 64 were discharged home (24.71%) vs 47 (17.84%) in the nonmobilized cohort (P = 0.0434), with no increase in readmission rates. In conclusion, mobilization on the day of surgery reduced length of stay by 1 day, with a higher percentage of patients being discharged home.

Relation of tranexamic acid therapy to length of stay in the hip fracture population.

Tranexamic acid (TXA) is a medication that is routinely used to minimize blood loss during surgery. There is minimal literature evaluating the effects of TXA in hip fractures in regards to length of stay, readmission rates, and location of discharge. This study included adult patients who were admitted for hip fracture that required surgery over a 22-month period (May 2017-February 2019). A total of 525 hip fractures were operated on during this time period. Retrospective analysis was performed on patients treated with TXA (n = 27) vs those who were not (n = 498). Primary outcomes were length of stay, disposition after discharge, need for transfusion, mobilization with therapy, and readmission rates. TXA during hip fractures reduced median length of stay in the hip fracture cohort to 3 vs 5 days (P < 0.01). Patients were more likely to be discharged home as opposed to a nursing facility. Patients who received TXA during their hip fracture surgery were less likely to need transfusions while admitted (P < 0.01). No increased readmission rates were seen within 30 days after discharge (P = 0.59). In conclusion, when indicated, TXA appears to be safe for utilization in hip fracture surgery, resulting in decreased length of stay, less transfusions, and no increase in readmission rates.

A Community Orthopaedic Residency Approach to Education and Training During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic has rapidly affected all facets of everyday life including the practice of medicine. Hospital systems and medical practices have evolved to protect patients, physicians, and staff and conserve personal protective equipment and resources. Orthopaedic practices have been specifically affected by social distancing and stay at home guidelines, limiting in-office practice and elective surgery restrictions. This, in turn, has had an effect on resident education. Previous literature has been published regarding how academic programs have adjusted to these changes. However, the effects on smaller orthopaedic residencies with nonacademic faculty has not been discussed. The orthopaedic residency at Baylor University Medical Center of Dallas is a fifteen-resident program with a combination of hospital employed and private practice faculty. We adjusted our resident education in mid-March 2020 to keep residents safe while trying to maximize surgical and clinical education and outside research. GOALS: Our goals were to come up with a plan allowed for continuing high-level patient care and resident education while protecting residents and limiting burnout. MODEL: We devised a four-team system with five-day call periods. Interactions between teams were strictly minimized. We also moved to a web-based academic curriculum and devised a system for safe resident participation in surgical cases. The model has been adjusted based on attending and resident feedback. CONCLUSION: Until we develop effective treatments or vaccination for COVID-19, there is a possibility that it will be an ongoing threat. Resident education must also adapt to the changing environment while continuing to provide residents safe opportunities for patient care, didactic education, and research. We believe we have come up with a sustainable, adaptable model for resident education during this challenging time.

Robert Wilson Jackson, MD (1932-2010).

This article commemorates the life and contributions of one of the most influential sports surgeons in the history of orthopedic surgery, Dr. Robert Jackson.

James Pat Evans, MD, 1930-2019.

This biographical sketch of Dr. J. Pat Evans commemorates the life and contributions of one of the most influential sports surgeons in the history of orthopedic surgery, drawing on articles written in remembrance of him and his contributions to orthopedic surgery and sports medicine.

Ruth Jackson, MD, 1902-1994.

This article commemorates Dr. Ruth Jackson for her contributions to orthopedic surgery and her status as a trailblazer for women in orthopedic surgery, becoming the first female member of the American Academy of Orthopedic Surgeons. She died on August 28, 1994, at the age of 91.

Relation of length of stay and other hospital variables to posttraumatic stress disorder and depression after orthopedic trauma.

Posttraumatic stress disorder (PTSD) and depression are common following orthopedic trauma. This study examined the relationship between injury- and hospital-related variables and PTSD and depression at baseline and 12 months after orthopedic trauma. This longitudinal, prospective cohort study examined adult orthopedic trauma patients admitted ≥24 hours to a level I trauma center. Non-English/Spanish-speaking and cognitively impaired patients were excluded. The Primary Care PTSD screen and PTSD Checklist-Civilian version assessed PTSD, and the Patient Health Questionnaire 8-Item assessed depression. Demographic and hospital-related variables were examined (e.g., hospital length of stay, Injury Severity Score, Glasgow Coma Scale). For 160 participants, PTSD prevalence was 23% at baseline and 21% at 12 months. Depression prevalence was 28% at baseline and 29% at 12 months. Ventilation (P = 0.023, P = 0.006) and prolonged length of stay (P = 0.008, P = 0.003) were correlated with baseline PTSD and depression. Injury etiology (P = 0.008) and Injury Severity Score (P = 0.013) were associated with baseline PTSD. Intensive care unit admission (P = 0.016, P = 0.043) was also correlated with PTSD at baseline and 12 months. Ventilation (P = 0.002, P = 0.040) and prolonged length of stay (P < 0.001, P = 0.001) were correlated with 12-month PTSD and depression. Early and continued screenings with potential interventions could benefit patients' physical and mental rehabilitation after orthopedic injury.

Psychological morbidity and functional impairment following traumatic pelvic injury.

Pelvic injuries often result from high-energy trauma and lead to significant functional impairment. While the physical outcomes of these injuries have been widely studied, the psychological consequences remain largely unexplored. The purpose of this study was to examine psychosocial and functional outcomes of patients with pelvic trauma in the year after injury. The sample (N = 32) consisted of adult patients with traumatic pelvic injures, as defined by ICD-9 codes, who were admitted to a Level I Trauma Center for at least 24 h. Participants were primarily female (53%) with a mean age of 48.7 years (SD = 17.9). Demographic, injury-related, and psychosocial data (e.g., posttraumatic stress disorder (PTSD), depression, alcohol use, quality of life, pain, return to work) were gathered at the time of hospitalization as well as at 3-, 6-, and 12 month follow-ups. Mixed regression models were used to examine the outcome variables over time. There were significant decreases in pain and alcohol use at each follow-up compared to baseline. However, despite the decrease, the levels of pain and alcohol use remained high. Physical and mental health also decreased significantly, indicating worsened functioning and lowered quality of life. Neither PTSD nor depression changed significantly over time, indicating that participants' symptoms were not likely to improve. These data suggest that sustaining a traumatic pelvic injury increases the risk of diminished quality of life, both mentally and physically. Even one-year post-injury, participants experienced moderate physical pain and higher levels of PTSD, depression, and problematic alcohol use than would be expected in the general population. These findings highlight the need for an interdisciplinary approach to treating patients with pelvic injuries, including psychological screening and intervention in acute care and throughout recovery.

An analysis of outcomes of reconstruction or amputation after leg-threatening injuries.

BACKGROUND: Limb salvage for severe trauma has replaced amputation as the primary treatment in many trauma centers. However, long-term outcomes after limb reconstruction or amputation have not been fully evaluated. METHODS: We performed a multicenter, prospective, observational study to determine the functional outcomes of 569 patients with severe leg injuries resulting in reconstruction or amputation. The principal outcome measure was the Sickness Impact Profile, a multidimensional measure of self-reported health status (scores range from 0 to 100; scores for the general population average 2 to 3, and scores greater than 10 represent severe disability). Secondary outcomes included limb status and the presence or absence of major complications resulting in rehospitalization. RESULTS: At two years, there was no significant difference in scores for the Sickness Impact Profile between the amputation and reconstruction groups (12.6 vs. 11.8, P=0.53). After adjustment for the characteristics of the patients and their injuries, patients who underwent amputation had functional outcomes that were similar to those of patients who underwent reconstruction. Predictors of a poorer score for the Sickness Impact Profile included rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), smoking, and involvement in disability-compensation litigation. Patients who underwent reconstruction were more likely to be rehospitalized than those who underwent amputation (47.6 percent vs. 33.9 percent, P=0.002). Similar proportions of patients who underwent amputation and patients who underwent reconstruction had returned to work by two years (53.0 percent and 49.4 percent, respectively). CONCLUSIONS: Patients with limbs at high risk for amputation can be advised that reconstruction typically results in two-year outcomes equivalent to those of amputation.

Health-care costs associated with amputation or reconstruction of a limb-threatening injury.

BACKGROUND: Recent reports have suggested that functional outcomes are similar following either amputation or reconstruction of a severely injured lower extremity. The goal of this study was to compare two-year direct health-care costs and projected lifetime health-care costs associated with these two treatment pathways. METHODS: Two-year health-care costs were estimated for 545 patients with a unilateral limb-threatening lower-extremity injury treated at one of eight level-I trauma centers. Included in the calculation were costs related to (1) the initial hospitalization, (2) all rehospitalizations for acute care related to the limb injury, (3) inpatient rehabilitation, (4) outpatient doctor visits, (5) outpatient physical and occupational therapy, and (6) purchase and maintenance of prosthetic devices. All dollar figures were inflated to constant 2002 dollars with use of the medical service Consumer Price Index. To estimate projected lifetime costs, the number of expected life years was multiplied by an estimate of future annual health-care costs and added to an estimate of future costs associated with the purchase and maintenance of prosthetic devices. RESULTS: When costs associated with rehospitalizations and post-acute care were added to the cost of the initial hospitalization, the two-year costs for reconstruction and amputation were similar. When prosthesis-related costs were added, there was a substantial difference between the two groups ($81,316 for patients treated with reconstruction and $91,106 for patients treated with amputation). The projected lifetime health-care cost for the patients who had undergone amputation was three times higher than that for those treated with reconstruction ($509,275 and $163,282, respectively). CONCLUSIONS: These estimates add support to previous conclusions that efforts to improve the rate of successful reconstructions have merit. Not only is reconstruction a reasonable goal at an experienced level-I trauma center, it results in lower lifetime costs.

Recombinant human BMP-2 and allograft compared with autogenous bone graft for reconstruction of diaphyseal tibial fractures with cortical defects. A randomized, controlled trial.

BACKGROUND: Currently, the treatment of diaphyseal tibial fractures associated with substantial bone loss often involves autogenous bone-grafting as part of a staged reconstruction. Although this technique results in high healing rates, the donor-site morbidity and potentially limited supply of suitable autogenous bone in some patients are commonly recognized drawbacks. The purpose of the present study was to investigate the benefit and safety of the osteoinductive protein recombinant human bone morphogenetic protein-2 (rhBMP-2) when implanted on an absorbable collagen sponge in combination with freeze-dried cancellous allograft. METHODS: Adult patients with a tibial diaphyseal fracture and a residual cortical defect were randomly assigned to receive either autogenous bone graft or allograft (cancellous bone chips) for staged reconstruction of the tibial defect. Patients in the allograft group also received an onlay application of rhBMP-2 on an absorbable collagen sponge. The clinical evaluation of fracture-healing included an assessment of pain with full weight-bearing and fracture-site tenderness. The Short Musculoskeletal Function Assessment (SMFA) was administered before and after treatment. Radiographs were used to document union, the presence of extracortical bridging callus, and incorporation of the bone-graft material. RESULTS: Fifteen patients were enrolled in each group. The mean length of the defect was 4 cm (range, 1 to 7 cm). Ten patients in the autograft group and thirteen patients in the rhBMP-2/allograft group had healing without further intervention. The mean estimated blood loss was significantly less in the rhBMP-2/allograft group. Improvement in the SMFA scores was comparable between the groups. No patient in the rhBMP-2/allograft group had development of antibodies to BMP-2; one patient had development of transient antibodies to bovine type-I collagen. CONCLUSIONS: The present study suggests that rhBMP-2/allograft is safe and as effective as traditional autogenous bone-grafting for the treatment of tibial fractures associated with extensive traumatic diaphyseal bone loss. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

Occurrence, Distribution, and Polymerase Chain Reaction-Based Detection of Resistance to Sterol Demethylation Inhibitor Fungicides in Populations of Blumeriella jaapii in Michigan.

ABSTRACT The intensive use of site-specific fungicides in agricultural production provides a potent selective mechanism for increasing the frequency of fungicide-resistant isolates in pathogen populations. Practical resistance occurs when the frequency and levels of resistance are great enough to limit the effectiveness of disease control in the field. Cherry leaf spot (CLS), caused by the fungus Blumeriella jaapii, is a major disease of cherry trees in the Great Lakes region. The site-specific sterol demethylation inhibitor fungicides (DMIs) have been used extensively in the region. In 2002, CLS control failed in a Michigan orchard that had used the DMI fenbuconazole exclusively for 8 years. That control failure and our observations from around the state suggested that practical resistance had developed in B. jaapii. Field trial data covering 1989 to 2005 for the DMIs fenbuconazole and tebuconazole supported observations of reduced efficacy of DMIs for controlling CLS. To verify the occurrence of fungicide-resistant B. jaapii, monoconidial isolates were collected in two surveys and tested using a fungicide-amended medium. In one survey, 137 isolates from sites with different DMI histories (no known history, mixed or alternated with other fungicides, and exclusive use) were tested against 12 concentrations of fenbuconazole, tebuconazole, myclobutanil, and fenarimol. Isolates from sites with no prior DMI use were DMI sensitive (DMI(S) = no colony growth at 0.2 mug/ml a.i.) whereas the isolates from the site with prior exclusive use showed growth at DMI concentrations 3 to >100 times higher, and were rated as DMI resistant (DMI(R)). A second survey examined 1,530 monoconidial isolates, including 1,143 from 62 orchard sites in Michigan, where DMIs had been used to control CLS. Resistance to fenbuconazole was detected in 99.7% of the orchard isolates. All isolates from wild cherry trees were sensitive and isolates from feral and dooryard trees showed a range of sensitivities. A polymerase chain reaction (PCR)-based detection method for identifying B. jaapii and DMI(R) was developed and tested. The species-specific primer pair (Bj-F and Bj-R) based on introns in the CYP51 gene of B. jaapii, and the DMI(R)-specific primer pair (DMI-R-Bj-F and DMI-R-Bj-R) based on an insert found upstream of CYP51 in all DMI(R) isolates, provided an accurate and rapid method for detecting DMI(R) B. jaapii. The PCR-based identification method will facilitate timely decision making and continued monitoring of DMI(R) subpopulations in response to management programs.

Vertically unstable pelvic fractures fixed with percutaneous iliosacral screws: does posterior injury pattern predict fixation failure?

OBJECTIVE: To measure the failure rate of percutaneous iliosacral screw fixation of vertically unstable pelvic fractures and particularly to test the hypothesis that fixations in which the posterior injury is a vertical fracture of the sacrum are more likely to fail than fixations with dislocations or fracture-dislocations of the sacroiliac joint. DESIGN: Retrospective review. SETTING: Level 1 trauma center. METHODS: All patients with pelvic fractures admitted between January 1, 1993, and December 31, 1998, were identified from the trauma registry. Hospital records were used to identify patients treated with iliosacral screws. Radiologic studies were examined to identify patients who had unequivocally vertically unstable pelvic fractures. Immediate postoperative and follow- up anteroposterior, inlet, and outlet radiographs from a minimum of 12 months postinjury were examined. Position, length, and numbers of iliosacral screws and any evidence of screw failure (eg, bending or breakage) were recorded. Residual postoperative displacement and late displacement of the posterior pelvis were measured. The main outcome measure was failure, defined as at least 1cm of combined vertical displacement of the posterior pelvis compared with immediate postoperative position. The main analysis was for association between fracture pattern and failure. Patient demographic data, iliosacral screw position, and anterior pelvic fixation method also were studied. RESULTS: The study group comprised 62 patients with unequivocally vertically unstable pelvic fractures in whom the posterior injury was treated with closed reduction and percutaneous iliosacral screw fixation. Of patients, 32 had dislocations or fracture-dislocations of the sacroiliac joint, and 30 had vertical fractures of the sacrum. Fixation failed in four patients, all with vertical sacral fractures and all within the first 3 weeks after surgery. These four patients required revision fixation. In two further cases with vertical sacral fractures, there was evidence that the fracture had only barely been held by the fixation, but these fractures healed, and followup radiographs did not meet the displacement criteria for failure. A vertical sacral fracture pattern was associated significantly with failure (Fisher exact test, P = 0.04); the excess risk of failure compared with sacroiliac joint injury was 13% (95% confidence interval 1% to 25%). There was no significant association between failure and anterior fixation method, iliosacral screw arrangement or length, or any demographic or injury variable. CONCLUSIONS: Percutaneous iliosacral screw fixation is a useful technique in the management of vertically unstable pelvic fractures, but a vertical sacral fracture should make the surgeon more wary of fixation failure and loss of reduction.

Antibiotic use in plant agriculture.

Antibiotics have been used since the 1950s to control certain bacterial diseases of high-value fruit, vegetable, and ornamental plants. Today, the antibiotics most commonly used on plants are oxytetracycline and streptomycin. In the USA, antibiotics applied to plants account for less than 0.5% of total antibiotic use. Resistance of plant pathogens to oxytetracycline is rare, but the emergence of streptomycin-resistant strains of Erwinia amylovora, Pseudomonas spp., and Xanthomonas campestris has impeded the control of several important diseases. A fraction of streptomycin-resistance genes in plant-associated bacteria are similar to those found in bacteria isolated from humans, animals, and soil, and are associated with transfer-proficient elements. However, the most common vehicles of streptomycin-resistance genes in human and plant pathogens are genetically distinct. Nonetheless, the role of antibiotic use on plants in the antibiotic-resistance crisis in human medicine is the subject of debate.

Prospective Evaluation of Posttraumatic Stress Disorder in Injured Patients With and Without Orthopaedic Injury.

OBJECTIVES: The study purposes were to prospectively evaluate occurrence of posttraumatic stress (PTS) symptoms at hospital admission and 6 months later in patients with orthopaedic injury; to explore differences in PTS symptoms in those with and without orthopaedic injury; and to determine whether PTS symptoms are influenced by orthopaedic injury type. DESIGN: Prospective, longitudinal observational study. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Two hundred fifty-nine participants admitted for at least 24 hours. MAIN OUTCOME MEASUREMENTS: The Primary Care Posttraumatic Stress Disorder (PTSD) Screen (PC-PTSD) measured PTSD symptoms during hospitalization. The PTSD Checklist-Civilian Version (PCL-C) measured PTS symptoms at 6 months. RESULTS: In orthopaedic patients, 28% had PTS at 6 months, compared with 34% of nonorthopaedic patients. Odds ratios (ORs) were calculated to determine the influence of pain, physical and mental function, depression, and work status. At 6 months, if the pain score was 5 or higher, the odds of PTS symptoms increased to 8.38 (3.55, 19.8) (P < 0.0001). Those scoring below average in physical function were significantly more likely to have PTS symptoms [OR = 7.60 (2.99, 19.32), P < 0.0001]. The same held true for mental functioning and PTS [OR = 11.4 (4.16, 30.9), P < 0.0001]. Participants who screened positive for depression had a 38.9 (14.5, 104) greater odds (P < 0.0001). Participants who did not return to work after injury at 6 months were significantly more likely to have PTS [OR = 16.5 (1.87, 146), P = 0.012]. CONCLUSIONS: PTSD is common in patients after injury, including those with orthopaedic trauma. At 6 months, pain of 5 or greater, poor physical and mental function, depression, and/or not returning to work seem to be predictive of PTSD. Orthopaedic surgeons should identify and refer for PTSD treatment given the high incidence postinjury. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

The insensate foot following severe lower extremity trauma: an indication for amputation?

BACKGROUND: Plantar sensation is considered to be a critical factor in the evaluation of limb-threatening lower extremity trauma. The present study was designed to determine the long-term outcomes following the treatment of severe lower extremity injuries in patients who had had absent plantar sensation at the time of the initial presentation. METHODS: We examined the outcomes for a subset of fifty-five subjects who had had an insensate extremity at the time of presentation. The patients were divided into two groups on the basis of the treatment in the hospital: an insensate amputation group (twenty-six patients) and an insensate salvage group (twenty-nine patients), the latter of which was the group of primary interest. In addition, a control group was constructed from the parent cohort so that the patients in the study groups could be compared with patients in whom plantar sensation was present and in whom the limb was reconstructed. Patient and injury characteristics as well as functional and health-related quality-of-life outcomes at twelve and twenty-four months after the injury were compared between the subjects in the insensate salvage group and those in the other two groups. RESULTS: The patients in the insensate salvage group did not report or demonstrate significantly worse outcomes at twelve or twenty-four months after the injury compared with subjects in the insensate amputation or sensate control groups. Among the patients in whom the limb was salvaged (that is, those in the insensate salvage and sensate control groups), an equal proportion (approximately 55%) had normal plantar sensation at two years after the injury, regardless of whether plantar sensation had been reported to be intact at the time of admission. No significant differences were noted among the three groups with regard to the overall, physical, or psychosocial scores. At two years after the injury, only one patient in the insensate salvage group had absent plantar sensation. CONCLUSIONS: Outcome was not adversely affected by limb salvage, despite the presence of an insensate foot at the time of presentation. More than one-half of the patients who had presented with an insensate foot that was treated with limb reconstruction ultimately regained sensation at two years. Initial plantar sensation is not prognostic of long-term plantar sensory status or functional outcomes and should not be a component of a limb-salvage decision algorithm.

Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up.

BACKGROUND: A recent study demonstrated that patients treated with amputation and those treated with reconstruction had comparable functional outcomes at two years following limb-threatening trauma. The present study was designed to determine whether those outcomes improved after two years, and whether differences according to the type of treatment emerged. METHODS: Three hundred and ninety-seven patients who had undergone amputation or reconstruction of the lower extremity were interviewed by telephone at an average of eighty-four months after the injury. Functional outcomes were assessed with use of the physical and psychosocial subscores of the Sickness Impact Profile (SIP) and were compared with similar scores obtained at twenty-four months. RESULTS: On the average, physical and psychosocial functioning deteriorated between twenty-four and eighty-four months after the injury. At eighty-four months, one-half of the patients had a physical SIP subscore of > or = 10 points, which is indicative of substantial disability, and only 34.5% had a score typical of a general population of similar age and gender. There were few significant differences in the outcomes according to the type of treatment, with two exceptions. Compared with patients treated with reconstruction for a tibial shaft fracture, those with only a severe soft-tissue injury of the leg were 3.1 times more likely to have a physical SIP subscore of 5 points (p < 0.05) and those treated with a through-the-knee amputation were 11.5 times more likely to have a physical subscore of 5 points (p < 0.05). There were no significant differences in the psychosocial outcomes according to treatment group. Patient characteristics that were significantly associated with poorer outcomes included older age, female gender, nonwhite race, lower education level, living in a poor household, current or previous smoking, low self-efficacy, poor self-reported health status before the injury, and involvement with the legal system in an effort to obtain disability payments. Except for age, predictors of poor outcome were similar at twenty-four and eighty-four months after the injury. CONCLUSIONS: The results confirm previous conclusions that reconstruction for the treatment of injuries below the distal part of the femur typically results in functional outcomes equivalent to those of amputation. Regardless of the treatment option, however, long-term functional outcomes are poor. Priority should be given to efforts to improve post-acute-care services that address secondary conditions that compromise optimal recovery.

Recombinant human bone morphogenic protein-2 in fracture care.

Recombinant human bone morphogenic protein-2 (rhBMP-2) is an osteoinductive protein that is now available for the acute treatment of open tibial fracture. Data from preclinical and clinical trials support its role in fracture care. This article summarizes data from two randomized controlled clinical trials investigating the safety and efficacy of rhBMP-2 in patients with open tibial shaft fractures and tibial fractures with bone defects. Also included is a summary of an economic analysis that examined the cost impact of rhBMP-2 from a hospital and payor perspective.