Proximal Humerus Fractures: How to Achieve Best Outcomes.

The treatment of proximal humerus fractures remains controversial. Although treatment modalities may vary, the goal of obtaining the best outcomes for patients remains the same. Most proximal humerus fractures can be treated nonsurgically but should still be managed actively. Deciding on surgical management requires a good understanding of indications and options. Indications for open reduction and internal fixation include younger or active patients with displaced two-, three-, and four-part fractures as well as fracture-dislocations with head-split patterns. Obtaining ideal outcomes requires anatomic reduction with restoration of the medial calcar as well as optimal position of implants to favor biomechanical stability. Reverse total shoulder arthroplasty is indicated for patients with severe and displaced fractures in older or low-demand patients. Obtaining the best functional outcomes depends on implant position, tuberosity healing, and early surgical intervention. Regardless of the treatment modality, these fractures can be challenging, and proper patient rehabilitation must be implemented. Future research will focus on patient selection and improving surgical techniques to maximize outcomes.

Fractures of the Talus and Pantalar Dislocations.

Talar fractures and pantalar dislocations are usually the results of high-energy trauma. Dislocations and open injuries are managed urgently. Temporary stabilization with splinting, Kirschner wires, or external fixation may be performed until the soft tissues are ready for definitive fixation. A CT scan is critical to identify all injuries and is helpful in planning treatment including reduction of dislocations and definitive fixation. Lateral and posterior process fractures are often missed initially and require a high index of suspicion.

High rate of avascular necrosis but excellent patient-reported outcomes after open reduction and internal fixation (ORIF) of proximal humerus fracture dislocations: should ORIF be considered as primary treatment?

BACKGROUND: Proximal humerus fracture dislocations, excluding 2-part greater tuberosity fracture dislocations, are rare injuries. Outcomes after open reduction and internal fixation (ORIF) of these injuries have not been well described in the literature. The purpose of this study was to report the radiographic and functional outcomes of patients who underwent ORIF of a proximal humerus fracture dislocation. METHODS: All skeletally mature patients who underwent ORIF of a proximal humerus fracture dislocation between 2011 and 2020 were identified. Patients with isolated greater tuberosity fracture dislocations were excluded. The primary outcome was American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score at a minimum of 2 years. Secondary outcomes were the development of avascular necrosis (AVN) and reoperation rate. RESULTS: Twenty-six patients met the inclusion criteria. The mean age was 45 years (standard deviation 16), and 77% were men. Median time to reduction and surgery was 1 day (interquartile range [IQR] 1-5). There were 2 (8%) Neer 2-part fractures, 7 (27%) 3-part, and 17 (65%) 4-part fractures. Fifty-four percent (54%) involved the anatomic neck and 31% included a head-split component. Thirty-nine percent (39%) were anterior dislocations. The rate of AVN was 19%. The reoperation rate was 15%. Reoperations included removal of hardware (2), subscapularis repair (1), and manipulation under anesthesia (1). No patients went on to arthroplasty. ASES scores were available for 22 patients (84%) including 4 of 5 patients with AVN. The median ASES score at a mean of 6.0 years postoperatively was 98.3 (IQR 86.7-100, range 63.3-100) and was not different in those with or without AVN (median 98.3 vs. 92.0, P = .175). Only the presence of medial comminution and nonanatomic head shaft alignment on postoperative radiographs were associated with increased risk of AVN. CONCLUSION: Radiographic rates of AVN (19%) and reoperation (15%) were high in this series of patients undergoing ORIF of proximal humerus fracture dislocations. Despite this, none of the patients required arthroplasty, and patient-reported outcome scores at an average of 6 years postinjury were excellent, with a median ASES score of 98.5. ORIF should be considered as primary method of treatment in proximal humerus fracture dislocations not only in young patients but also middle-aged patients.

Treatment of critical-sized bone defects: clinical and tissue engineering perspectives.

Critical-sized bone defects are defined as those that will not heal spontaneously within a patient's lifetime. Current treatment options include vascularized bone grafts, distraction osteogenesis, and the induced membrane technique. The induced membrane technique is an increasingly utilized method with favorable results including high rates of union. Tissue engineering holds promise in the treatment of large bone defects due to advancement of stem cell biology, novel biomaterials, and 3D bioprinting. In this review, we provide an overview of the current operative treatment strategies of critical-sized bone defects as well as the current state of tissue engineering for such defects.

Survival after chemotherapy and stem cell transplant followed by delayed craniospinal irradiation is comparable to upfront craniospinal irradiation in pediatric embryonal brain tumor patients.

Pediatric embryonal brain tumor patients treated with craniospinal irradiation (CSI) are at risk for adverse effects, with greater severity in younger patients. Here we compare outcomes of CSI vs. high-dose chemotherapy (HD), stem cell transplant (SCT) and delayed CSI in newly diagnosed patients. Two hundred one consecutive patients treated for medulloblastoma (72 %), supratentorial primitive neuroectodermal tumor (sPNET; 18 %) or pineoblastoma (10 %) at two institutions between 1988 and 2014 were retrospectively identified. Progression free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method and compared by log-rank tests. Adjuvant CSI regimens were used for 56 % of patients (upfront-CSI), and HD/SCT regimens were used in 32 % of patients. HD/SCT patients were significantly younger than those receiving upfront-CSI (2.9 vs. 7.8 years; P < 0.0001). There were no differences in metastases, extent of resection, or CSI dose between upfront-CSI and HD/SCT patients, but median follow-up was shorter in the HD/SCT group (6.2 vs. 3.9 years; P = 0.007). There were no significant outcome differences between upfront-CSI and HD/SCT patients who received CSI as a prophylaxis or following relapse (OS 66 % vs. 61 %, P = 0.13; PFS 67 % vs. 62 %, P = 0.12). Outcomes were equivalent when restricting analyses to HD/SCT patients who received prophylactic CSI prior to relapse (OS 66 % vs. 65 %, P = 0.5; PFS 67 % vs. 74 %, P = 0.8). At last follow-up, 48 % of HD/SCT patients had received neither definitive nor salvage radiotherapy. In this retrospective cohort, outcomes with adjuvant HD/SCT followed by delayed CSI are comparable to upfront-CSI for carefully surveyed pediatric embryonal brain tumor patients. Future prospective studies are required to validate this finding, and also to assess the impact of delayed CSI on neurocognitive outcomes.

Orthopaedic Injury Patterns in Intimate Partner Violence: Defensive Wounds and Fracture Patterns: A Systematic Literature Review.

BACKGROUND: Intimate partner violence (IPV) is a prevalent issue in the United States, despite universal screening measures for women of reproductive age. Orthopaedic surgeons have a unique opportunity to intervene in cases of IPV as musculoskeletal injuries, including fractures, are the second most common type of injury seen in IPV patients. This systematic literature review aims to identify patterns in musculoskeletal injuries caused by IPV to increase identification of patients afflicted by IPV. METHODS: A comprehensive search of PubMed, PsycINFO, and Web of Science yielded 316 articles. Included were cohort studies and literature reviews of patients with an IPV-associated orthopaedic injury. Excluded were case studies, perspective articles, material predating 2003, and studies with pediatric or elderly populations. Sixteen articles met criteria. RESULTS: Data supported historical findings that musculoskeletal injury is the second most common injury in patients with IPV, with upper extremity fractures prevailing. Minimally displaced phalanges fractures were most common (9.9%-64%), and isolated ulnar fractures had significant relative risk of IPV association (8.5-12.8). Patients with multiple fractures of varying chronicity were more likely to be victims of IPV (sensitivity 25.2%, specificity 99.2%, positive predictive value 96.2%), and these chronic fractures matched patterns of acute injury caused by IPV. New findings in male victims included a higher proportion of lower extremity and pelvic fractures seen in male cohorts. CONCLUSION: This study synthesizes evidence of IPV-related orthopaedic injuries, offering objective criteria for identifying victims. Despite limitations in fracture descriptions, the findings aid various physicians in recognizing IPV victims. Considering ongoing IPV prevalence and screening challenges, further research on injury patterns is recommended. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors of Failure in 228 Periprosthetic Distal Femur Fractures: A Multicenter Study.

OBJECTIVES: To identify risk factors of reoperation to promote union or to address deep surgical-site infection (DSSI) in periprosthetic distal femur fractures treated with lateral distal femoral locking plates (LDFLPs). DESIGN: Multicenter retrospective cohort study. SETTING: Ten level-I trauma centers. PATIENT SELECTION CRITERIA: Patients with Orthopaedic Trauma Association/Association of Osteosynthesis (OTA/AO) 33A or 33C periprosthetic distal femur fractures who underwent surgical fixation between January 2012 and December 2019 exclusively using LDFLPs were eligible for inclusion. Patients with pathologic fractures or with follow-up less than 3 months without an outcome event (unplanned reoperation to promote union or for deep surgical infection) before this time point were excluded. Fracture fixation constructs used medial plates, intramedullary nails, or hybrid fixation constructs were excluded from analysis. OUTCOME MEASURES AND COMPARISONS: To examine the influence of patient demographics, injury characteristics, and features of the fracture fixation construct on the occurrence of unplanned reoperation to promote union or to address a DSSI. RESULTS: There was an 8.3% rate (19/228) of unplanned reoperation to promote union. Predictive factors for the need for reoperation to promote union included increasing body mass index (odds ratio [OR] = 1.09; 95% confidence interval [CI]: 1.02-1.16; P = 0.01), increasing number of screws in the distal fracture segment (OR = 1.73; 95% CI: 1.06-2.95; P = 0.03), and decreasing proportion of proximal segment screws that are locking (OR = 0.17; 95% CI: 0.03-0.70; P = 0.02) There was a 4.8% rate (11/228) of reoperation to address DSSI. There were no statistically significant predictive factors identified as risk factors of the need for reoperation to address DSSI ( P > 0.05). CONCLUSIONS: 8.3% of periprosthetic distal femur fractures treated at 10 centers with LDFLPs underwent unplanned reoperation to promote union. Increasing patient body mass index and increasing number of screws in the distal fracture segment were found to be predictive factors, whereas increased locking screws in the proximal segment were found to be protective. 4.8% of patients in this cohort underwent reoperation to address DSSI. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

Technical Factors Contributing to Nonunion in Supracondylar Distal Femur Fractures Treated With Lateral Locked Plating: A Risk-Stratified Analysis.

OBJECTIVE: To identify technical factors associated with nonunion after operative treatment with lateral locked plating. DESIGN: Retrospective cohort study. SETTING: Ten Level I trauma centers. PATIENT SELECTION CRITERIA: Adult patients with supracondylar distal femur fractures (OTA/AO type 33A or C) treated with lateral locked plating from 2010 through 2019. OUTCOME MEASURES AND COMPARISONS: Surgery for nonunion stratified by risk for nonunion. RESULTS: The cohort included 615 patients with supracondylar distal femur fractures. The median patient age was 61 years old (interquartile range: 46 -72years) and 375 (61%) were female. Observed were nonunion rates of 2% in a low risk of nonunion group (n = 129), 4% in a medium-risk group (n = 333), and 14% in a high-risk group (n = 153). Varus malreduction with an anatomic lateral distal femoral angle greater than 84 degrees, was associated with double the odds of nonunion compared to those without such varus [odds ratio, 2.1; 95% confidence interval (CI), 1.1-4.2; P = 0.03]. Malreduction by medial translation of the articular block increased the odds of nonunion, with 30% increased odds per 4 mm of medial translation (95% CI, 1.0-1.6; P = 0.03). Working length increased the odds of nonunion in the medium risk group, with an 18% increase in nonunion per 10-mm increase in working length (95% CI, 1.0-1.4; P = 0.01). Increased proximal screw density was protective against nonunion (odds ratio, 0.71; 95% CI, 0.53-0.92; P = 0.02) but yielded lower mRUST scores with each 0.1 increase in screw density associated with a 0.4-point lower mRUST (95% CI, -0.55 to -0.15; P < 0.001). Lateral plate length and type of plate material were not associated with nonunion. ( P > 0.05). CONCLUSIONS: Malreduction is a surgeon-controlled variable associated with nonunion after lateral locked plating of supracondylar distal femur fractures. Longer working lengths were associated with nonunion, suggesting that bridge plating may be less likely to succeed for longer fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Nail Plate Combination Fixation Versus Lateral Locked Plating for Distal Femur Fractures: A Multicenter Experience.

OBJECTIVES: To (1) report on clinical, radiographic, and functional outcomes after nail-plate fixation (NPF) of distal femur fractures and (2) compare outcomes after NPF with a propensity matched cohort of fractures treated with single precontoured lateral locking plates. DESIGN: Multicenter retrospective cohort study. SETTING: Ten Level 1 trauma centers. PATIENTS/PARTICIPANTS: Patients with OTA/AO 33A or 33C fractures. INTERVENTION: Fixation with (1) retrograde intramedullary nail combined with lateral locking plate (n = 33) or (2) single precontoured lateral locking plate alone (n = 867). MAIN OUTCOME MEASUREMENTS: The main outcomes of interest were all-cause unplanned reoperation and presence of varus collapse at final follow-up. RESULTS: One nail-plate patient underwent unplanned reoperation excluding infection and 2 underwent reoperation for infection at an average of 57 weeks after surgery. No nail-plate patients required unplanned reoperation to promote union and none exhibited varus collapse. More than 90% were ambulatory with no or minimal pain at final follow-up. In comparison, 7 of the 30 matched lateral locked plating patients underwent all-cause unplanned reoperation excluding infection (23% vs. 3%, P = 0.023), and an additional 3 lateral locked plating patients were found to have varus collapse on final radiographs (10% vs. 0%, P = 0.069). CONCLUSIONS: Despite a high proportion of high-energy, open, and comminuted fractures, no NPF patients underwent unplanned reoperation to promote union or demonstrated varus collapse. Propensity score matched analysis revealed significantly lower rates of nonunion for NPF compared with lateral locked plating alone. Larger studies are needed to identify which distal femur fracture patients would most benefit from NPF. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictors of Deep Infection After Distal Femur Fracture: A Multicenter Study.

OBJECTIVES: To identify potentially modifiable risk factors for deep surgical site infection after distal femur fracture. DESIGN: Multicenter retrospective cohort study. SETTING: Ten Level-I trauma centers. PATIENTS/PARTICIPANTS: Patients with OTA/AO 33A or C distal femur fractures (n = 1107). INTERVENTION: Surgical fixation of distal femur fracture. MAIN OUTCOME MEASUREMENT: The outcome of interest was deep surgical site infection. RESULTS: There was a 7% rate (79/1107) of deep surgical site infection. In the multivariate analysis, predictive factors included alcohol abuse [odds ratio (OR) = 2.36; 95% confidence interval (CI), 1.17-4.46; P = 0.01], intra-articular injury (OR = 1.73; 95% CI, 1.01-3.00; P = 0.05), vascular injury (OR = 3.90; 95% CI, 1.63-8.61; P < 0.01), the use of topical antibiotics (OR = 0.50; 95% CI, 0.25-0.92; P = 0.03), and the duration of the surgery (OR = 1.15 per hour; 95% CI, 1.01-1.30; P = 0.04). There was a nonsignificant trend toward an association between infection and type III open fracture (OR = 1.73; 95% CI, 0.94-3.13; P = 0.07) and lateral approach (OR = 1.60; 95% CI, 0.95-2.69; P = 0.07). The most frequently cultured organisms were methicillin-resistant Staphylococcus aureus (22%), methicillin-sensitive Staphylococcus aureus (20%), and Enterobacter cloacae (11%). CONCLUSIONS: Seven percent of distal femur fractures developed deep surgical site infections. Alcohol abuse, intra-articular fracture, vascular injury, and increased surgical duration were risk factors, while the use of topical antibiotics was protective. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Reoperation to Promote Union in 1111 Distal Femur Fractures.

OBJECTIVES: To identify modifiable and nonmodifiable risk factors for reoperation to promote union after distal femur fracture. DESIGN: Multicenter retrospective cohort study. SETTING: Ten Level-I trauma centers. PATIENTS/PARTICIPANTS: Patients with OTA/AO 33A or C distal femur fractures (n = 1111). INTERVENTION: Surgical fixation of distal femur fracture. Fixation constructs were classified as lateral plate, dual plate, nail, or nail plate combination. MAIN OUTCOME MEASUREMENTS: The outcome of interest was unplanned reoperation to promote union. RESULTS: There was an 11% (121/1111) rate of unplanned reoperation to promote union. In the multivariate analysis, predictive factors included body mass index [odds ratio (OR) = 1.18; 95% confidence interval (CI), 1.06-1.32; P < 0.01], intra-articular fracture (OR = 1.57; 95% CI, 1.01-2.45; P = 0.04), type III open injury (OR = 2.29; 95% CI, 1.41-3.72; P < 0.01), the presence of medial comminution (OR = 1.85; 95% CI, 1.14-3.06; P = 0.01), and medial translation on postoperative radiographs (OR = 1.23 per one 10th of condylar width; 95% CI, 1.01-1.48; P = 0.03). Construct type was not significantly predictive. CONCLUSIONS: Eleven percent of distal femur fractures underwent unplanned reoperation to promote union. Body mass index, intra-articular fracture, type III open injury, medial comminution, and medial translation on postoperative radiographs were predictive factors. Construct type was not associated with unplanned reoperation; however, this conclusion was limited by small numbers in the dual plate and nail plate groups. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Public Insurance Payment Does Not Compensate Hospital Cost for Care of Long-Bone Fractures Requiring Additional Surgery to Promote Union.

OBJECTIVES: To quantify the total hospital costs associated with the treatment of lower extremity long-bone fracture aseptic and septic unhealed fracture, to determine if insurance adequately covers these costs, and to examine whether insurance type correlates with barriers to accessing care. DESIGN: Retrospective cohort study. SETTING: Academic Level II trauma center. PATIENTS: All patients undergoing operative treatment of OTA/AO classification 31, 32, 33, 41, 42, and 43 fractures between 2012 and 2020 at a single Level II trauma center with minimum of 1-year follow-up. MAIN OUTCOME MEASURES: The primary outcome was the total cost of treatment for all hospital-based episodes of care. Distance traveled from primary residence was measured as a surrogate for barriers to care. RESULTS: One hundred seventeen patients with uncomplicated fracture healing, 82 with aseptic unhealed fracture, and 44 with septic unhealed fracture were included in the final cohort. The median cost of treatment for treatment of septic unhealed fracture was $148,318 [interquartile range(IQR) 87,241-256,928], $45,230 (IQR 31,510-68,030) for treatment of aseptic unhealed fracture, and $33,991 (IQR 25,609-54,590) for uncomplicated fracture healing. The hospital made a profit on all patients with commercial insurance, but lost money on all patients with public insurance. Among patients with unhealed fracture, those with public insurance traveled 4 times further for their care compared with patients with commercial insurance (P = 0.004). CONCLUSIONS: Septic unhealed fracture of lower extremity long-bone fractures is an outsized burden on the health care system. Public insurance for both septic and aseptic unhealed fracture does not cover hospital costs. The increased distances traveled by our Medi-Cal and Medicare population may reflect the economic disincentive for local hospitals to care for publicly insured patients with unhealed fractures. LEVEL OF EVIDENCE: Economic Level V. See Instructions for Authors for a complete description of levels of evidence.

Operative Management of Hip Fractures Within 24 Hours in the Elderly is Achievable and Associated With Reduced Opiate Use.

Introduction: Morbidity and mortality benefits have been associated with prompt surgical treatment of geriatric hip fractures. The purpose of this study was to evaluate the impact of early (≤24 hr) vs delayed (>24 hr) time to operating room (TTOR) on 1) hospital length of stay and 2) total and post-operative opiate use in geriatric hip fractures. Materials and Methods: This study was a retrospective review of patients ≥65 years-old at the time of admission for surgery for hip fracture at a Level II academic trauma center. Outcome measures were length of stay (LOS), oral morphine equivalents (OME) throughout hospitalization. Patients were stratified into early and delayed TTOR groups and comparisons were made between groups. Results: Between the early (n = 75, 80.6%) and late (n = 18, 19.4%) groups, there were no differences in age, fracture pattern, type of treatment, preoperative opiate use, and perioperative non-oral pain management. The early group trended toward shorter total LOS (108.0 ± 67.2 hours vs 144.8 ± 103.7 hours, P = .066), but not post-operative LOS. Total OME usage was less in the early intervention group (92.5 ± 188.0 vs 230.2 ± 296.7, P = .015), in addition to reduced post-operative OME (81.3 ± 174.9 vs 213.3 ± 271.3, P = .012). There were no differences in evaluated potential delay sources such as primary language, use of surrogate decision makers, or need for advanced imaging. Discussion: Surgical treatment of geriatric hip/femur fractures in ≤24 hours from presentation is achievable and may be associated with reduced total inpatient opiate use, although daily use did not differ. Conclusion: Establishing institutional TTOR goals as part of an interdisciplinary hip fracture co-management clinical pathway can facilitate prompt care and contribute to recovery and less opiate use in these patients with highly morbid injuries.

Is the timing of fixation associated with fracture-related infection among tibial plateau fracture patients with compartment syndrome? A multicenter retrospective cohort study of 729 patients.

BACKGROUND: Tibial plateau fractures with an ipsilateral compartment syndrome are a clinical challenge with limited guidance regarding the best time to perform open reduction and internal fixation (ORIF) relative to fasciotomy wound closure. This study aimed to determine if the risk of fracture-related infection (FRI) differs based on the timing of tibial plateau ORIF relative to closure of ipsilateral fasciotomy wounds. METHODS: A retrospective cohort study identified patients with tibial plateau fractures and an ipsilateral compartment syndrome treated with 4-compartment fasciotomy at 22 US trauma centers from 2009 to 2019. The primary outcome measure was FRI requiring operative debridement after ORIF. The ORIF timing relative to fasciotomy closure was categorized as ORIF before, at the same time as, or after fasciotomy closure. Bayesian hierarchical regression models with a neutral prior were used to determine the association between timing of ORIF and infection. The posterior probability of treatment benefit for ORIF was also determined for the three timings of ORIF relative to fasciotomy closure. RESULTS: Of the 729 patients who underwent ORIF of their tibial plateau fracture, 143 (19.6%) subsequently developed a FRI requiring operative treatment. Patients sustaining infections were: 21.0% of those with ORIF before (43 of 205), 15.9% at the same time as (37 of 232), and 21.6% after fasciotomy wound closure (63 of 292). ORIF at the same time as fasciotomy closure demonstrated a 91% probability of being superior to before closure (RR, 0.75; 95% CrI, 0.38 to 1.10). ORIF after fasciotomy closure had a lower likelihood (45%) of a superior outcome than before closure (RR, 1.02; 95% CrI; 0.64 to 1.39). CONCLUSION: Data from this multicenter cohort confirms previous reports of a high FRI risk in patients with a tibial plateau fracture and ipsilateral compartment syndrome. Our results suggest that ORIF at the time of fasciotomy closure has the highest probability of treatment benefit, but that infection was common with all three timings of ORIF in this difficult clinical situation.

Delay of Antibiotic Administration Greater than 2 Hours Predicts Surgical Site Infection in Open Fractures.

AIMS: Antibiotic administration, severity of injury, and debridement are associated with surgical site infection (SSI) after internal fixation of open fractures. We sought to validate a time-dependent treatment effect of antibiotic administration. PATIENTS: Consecutive open fracture patients at a level 1 trauma center with minimum 30-day follow-up were identified from an orthopaedic registry from 2013-2017. METHODS: The primary endpoint was SSI within 90 days. A threshold time to antibiotic administration associated with SSI was ascertained by receiver-operator analysis. A Cox proportional hazards model adjusted for age, smoking, and drug use determined the treatment effect of antibiotic administration within the threshold period. RESULTS: Ten percent of 230 patients developed a SSI. There was a trend for patients who did not develop an SSI to receive antibiotics earlier than those who did develop an SSI (61 minutes, IQR 33-107 vs 83 minutes, IQR 40-186), p=0.053). Intravenous antibiotic administration after 120 minutes of presentation of an open fracture to emergency department was significantly associated with a 2.4 increased hazard of surgical site infection (p=0.036) within 90 days. CONCLUSION: Antibiotic administration greater than 120 minutes after ED presentation of an open fracture was associated with an increased risk of SSI.

Large Vessel Arteriopathy After Cranial Radiation Therapy in Pediatric Brain Tumor Survivors.

Among childhood cancer survivors, increased stroke risk after cranial radiation therapy may be caused by radiation-induced arteriopathy, but limited data exist to support this hypothesis. Herein, we assess the timing and presence of cerebral arteriopathy identified by magnetic resonance angiography (MRA) after cranial radiation therapy in childhood brain tumor survivors. In a cohort of 115 pediatric brain tumor survivors, we performed chart abstraction and prospective annual follow-up to assess the presence of large vessel cerebral arteriopathy by MRA. We identified 10 patients with cerebral arteriopathy. The cumulative incidence of arteriopathy 5 years post-cranial radiation therapy was 5.4% (CI 0.6%-10%) and 10 years was 16% (CI 4.6%-26%). One patient had an arterial ischemic stroke 2.4 years post-cranial radiation therapy in the distribution of a radiation-induced stenotic artery. We conclude that large vessel arteriopathies can occur within a few years of cranial radiation therapy and can become apparent on MRA in under a year.

Genomic insights in gynecologic cancer.

Recent technological advances in DNA sequencing have enabled a remarkably detailed understanding of the molecular changes that define gynecologic and other cancers. Several groups have carried out large-scale genomic analyses of ovarian, uterine, and most recently, cervical cancer. These analyses have led to new insights into the molecular changes characterizing these cancers, which provide insight into clinical outcomes. These molecular characterizations have similarly led to new genomic-based classification schemas, which may better stratify clinical outcomes, help prognosticate and guide treatments. Discovery of characteristic mutations may also provide potential new targets for molecularly targeted chemotherapies, as has been already described with poly-ADP ribose polymerase inhibitors and ovarian cancer. The purpose of this article is to provide an overview of the defining molecular abnormalities and markers in gynecologic cancer, to discuss the clinical implications, and to provide a comprehensive view of the current state of genomic knowledge in gynecologic cancer.

Rates and risk factors associated with unplanned hospital readmission after fusion for pediatric spinal deformity.

BACKGROUND CONTEXT: Short-term readmission rates are becoming widely used as a quality and performance metric for hospitals. Data on unplanned short-term readmission after spine fusion for deformity in pediatric patients are limited. PURPOSE: To characterize the rate and risk factors for short-term readmission after spine fusion for deformity in pediatric patients. STUDY DESIGN: This is a retrospective cohort study. PATIENT SAMPLE: Data were obtained from the State Inpatient Database from New York, Utah, Nebraska, Florida, North Carolina (years 2006-2010), and California (years 2006-2011). OUTCOME MEASURES: Outcome measures included 30- and 90-day readmission rates. MATERIALS AND METHODS: Inclusion criteria were patients aged 0-21 years, a primary diagnosis of spine deformity, and a primary 3+-level lumbar or thoracic fusion. Exclusion criteria included revision surgery at index admission and cervical fusion. Readmission rates were calculated and logistic analyses were used to identify independent predictors of readmission. RESULTS: There were a total of 13,287 patients with a median age of 14 years. Sixty-seven percent were girls. The overall 30- and 90-day readmission rates were 4.7% and 6.1%. The most common reasons for readmission were infection (38% at 30 days and 33% at 90 days), wound dehiscence (19% and 17%), and pulmonary complications (12% and 13%). On multivariate analysis, predictors of 30-day readmission included male sex (p=.008), neuromuscular (p<.0001) or congenital scoliosis (p=.006), Scheuermann kyphosis (p=.003), Medicaid insurance (p<.0001), length of stay of ≤3 days or ≥6 days (p<.0001), and surgery at a teaching hospital (p=.011). Surgery at a hospital performing >80 operations/year was associated with a 34% reduced risk of 30-day readmission (95% confidence interval 12%-50%, p=.005) compared with hospitals performing <20 operations/year. CONCLUSIONS: The short-term readmission rate for pediatric spine deformity surgery is driven by patient-related factors, as well as several risk factors that may be modified to reduce this rate.

Late Effects of Treatment of Pediatric Central Nervous System Tumors.

Central nervous system tumors represent the most common solid malignancy in childhood. Improvement in treatment approaches have led to a significant increase in survival rates, with over 70% of children now surviving beyond 5 years. As more and more children with CNS tumors have longer survival times, it is important to be aware of the long-term morbidities caused not only by the tumor itself but also by tumor treatment. The most common side effects including poor neurocognition, endocrine dysfunction, neurological and vascular late effects, as well as secondary malignancies, are discussed within this article.

Comparing Coordinated Versus Sequential Salpingo-Oophorectomy for BRCA1 and BRCA2 Mutation Carriers With Breast Cancer.

BACKGROUND: Women with breast cancer who carry BRCA1 or BRCA2 mutations must also consider risk-reducing salpingo-oophorectomy (RRSO) and how to coordinate this procedure with their breast surgery. We report the factors associated with coordinated versus sequential surgery and compare the outcomes of each. PATIENTS AND METHODS: Patients in our cancer risk database who had breast cancer and a known deleterious BRCA1/2 mutation before undergoing breast surgery were included. Women who chose concurrent RRSO at the time of breast surgery were compared to those who did not. RESULTS: Sixty-two patients knew their mutation carrier status before undergoing breast cancer surgery. Forty-three patients (69%) opted for coordinated surgeries, and 19 (31%) underwent sequential surgeries at a median follow-up of 4.4 years. Women who underwent coordinated surgery were significantly older than those who chose sequential surgery (median age of 45 vs. 39 years; P = .025). There were no differences in comorbidities between groups. Patients who received neoadjuvant chemotherapy were more likely to undergo coordinated surgery (65% vs. 37%; P = .038). Sequential surgery patients had longer hospital stays (4.79 vs. 3.44 days, P = .01) and longer operating times (8.25 vs. 6.38 hours, P = .006) than patients who elected combined surgery. Postoperative complications were minor and were no more likely in either group (odds ratio, 4.76; 95% confidence interval, 0.56-40.6). CONCLUSION: Coordinating RRSO with breast surgery is associated with receipt of neoadjuvant chemotherapy, longer operating times, and hospital stays without an observed increase in complications. In the absence of risk, surgical options can be personalized.