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.).

Pediatric Upper Extremity Trauma Secondary to All-terrain Vehicle Use.

All-terrain vehicles (ATVs) have become popular with respect to recreational activities. Multiple orthopaedic and pediatric organizations currently recommend limiting use of ATVs to older age groups of children with supervision. These recommendations have not generally been adhered to, resulting in a disproportionate number of pediatric orthopaedic trauma, specifically of the upper extremities. A retrospective review of patients 18-years-old and younger who presented to a single, Level I Trauma Center with ATV-related upper extremity trauma between 1996 and 2006 was undertaken to determine the impact of ATV use on the upper extremities of children. A total of 65 patients were identified with an average age of 12.3. Only 29.2% wore helmets and 73.8% were drivers. The hand and elbow were the most common injury sites in patients under age 12, elbow for those between ages 12 and 16, and wrist for those over age 16 (p = 0.031). Fractures/Dislocations were the most common injury in all age groups (p = 0.0077). The most performed surgical procedure was open reduction internal fixation of fractures, and patients required an average of 4.8 total operations. Patients who had non-isolated upper extremity injuries were associated with longer hospital stays (p = 0.011) but not ICU stays (p = 0.10). In order to reduce pediatric upper extremity injuries from ATVs, restrictions must be more stringent and safety education made a priority. (Journal of Surgical Orthopaedic Advances 32(2):088-091, 2023).

Episiotomy-assisted Incarcerated Femoral Nail Removal: Technical Note.

Introduction: Incarceration of intramedullary nails can pose a significant challenge. There are many reported techniques of nail removal, but when these fail, it can be difficult to determine how to proceed. Here, it is shown that a proximal femoral episiotomy can be used with great effect. Case Report: 64-year-old male developed hip arthritis. The patient had a solid antegrade femoral nail placed 22 years ago that required removal for a hip arthroplasty. A proximal femoral episiotomy-assisted approach was used with good results and patient outcome. Conclusion: There are several well described techniques to assist with incarcerated nail removal that all trauma surgeons should be familiar with. Proximal femoral episiotomy is a useful technique, every surgeon should have in their arsenal.

Outcomes of Tibiotalocalcaneal Hindfoot Fusion Nails Used for Acute Lower Extremity Trauma in a High-Risk Patient Population.

OBJECTIVE: To determine the outcomes of high-risk patients treated with tibiotalocalcaneal hindfoot fusion nails. DESIGN: Retrospective case series. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Between January 2007 and December 2016, 50 patients with significant medical comorbidities treated with a tibiotalocalcaneal hindfoot fusion nail in the setting of acute distal tibia and ankle trauma considered to be limb-threatening. INTERVENTION: Tibiotalocalcaneal hindfoot fusion nail. MAIN OUTCOME MEASUREMENTS: Two-year cumulative incidence of unplanned reoperation and estimated survival with limb salvage at 2 years. RESULTS: Of the 50 patients, 20 (38%) had an unplanned reoperation (mean: 2.5 reoperations), including 19 for implant removal, 11 for irrigation and debridement and/or placement of an antibiotic delivery device, and 4 for revision fusion. Three patients required amputation and 3 patients died within 2 years of injury, resulting in an estimated survival with limb salvage at 2 years of 79% (95% confidence interval: 67%-91%). After accounting for the competing risk of death and incomplete follow-up, the 2-year cumulative incidence of unplanned reoperation was 64% (95% confidence interval: 62%-67%). CONCLUSIONS: Patients in this series experienced a high rate of return to the operating room but a relatively low rate of amputation. Because patients were indicated for this course of treatment on the basis of comorbidities felt to put them at high risk of loss of limb with traditional treatment, acute hindfoot fusion nailing might represent a viable option in select high-risk patients and injuries. Clinicians should be aware that complications are still common. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Probabilistic atlas for the language network based on precision fMRI data from >800 individuals.

Two analytic traditions characterize fMRI language research. One relies on averaging activations across individuals. This approach has limitations: because of inter-individual variability in the locations of language areas, any given voxel/vertex in a common brain space is part of the language network in some individuals but in others, may belong to a distinct network. An alternative approach relies on identifying language areas in each individual using a functional 'localizer'. Because of its greater sensitivity, functional resolution, and interpretability, functional localization is gaining popularity, but it is not always feasible, and cannot be applied retroactively to past studies. To bridge these disjoint approaches, we created a probabilistic functional atlas using fMRI data for an extensively validated language localizer in 806 individuals. This atlas enables estimating the probability that any given location in a common space belongs to the language network, and thus can help interpret group-level activation peaks and lesion locations, or select voxels/electrodes for analysis. More meaningful comparisons of findings across studies should increase robustness and replicability in language research.

Urinary Bladder Matrix Grafting: A Simple and Effective Alternative to Flap Coverage for Wounds in High-Risk Orthopaedic Trauma Patients.

SUMMARY: Complex traumatic and/or infected wounds and their sequelae are a significant burden for high-volume trauma centers. Local or free flap coverage options are well described; however, they may be high risk in poor hosts with multiple comorbidities and active infections. In addition, flap coverage can result in delays in wound coverage depending on specialist availability. Porcine urinary bladder matrix grafting has been shown to be a simple definitive wound coverage option that can be performed without delay in multiple patient populations for wounds that would otherwise require flap coverage. The purpose of this article was to describe a technique for urinary bladder matrix grafting and report on a series of orthopaedic trauma patients treated with this technique.

Depyrogenation using Plasmas: A Novel Approach for Endotoxin Deactivation Using a Dielectric Barrier Discharge at Atmospheric Pressure.

Developing a low-cost depyrogenation process is vital in extending medical applicability of polymers that can be used in medicine. We present an overview of the plasma-based depyrogenation literature and address the need to develop a non-thermal plasma-based depyrogenation process for delicate materials such as chitosan. We present a low-cost plasma apparatus to treat chitosan powder in hermetically sealed bags. We decouple the experiments into two; depyrogenation experiments for dried standard endotoxin on glass slides, and chitosan modifications analysis through FTIR spectroscopy. We demonstrate depyrogenation efficacy with up to a 4-log reduction in endotoxin levels and discuss minor changes observed in plasma-treated chitosan.

Medial sided articular impaction in tibial plateau fractures.

INTRODUCTION: Tibial plateau fractures are a heterogenous group of injuries with a variable amount of articular injury and are commonly associated with lateral sided articular impaction. Previous work has focused on describing the morphology of tibial plateau fractures, but has neglected description of medial sided articular impaction. The aim of this investigation was to assess the morphology of medial sided articular impaction in tibial plateau fractures, with specific attention directed toward the frequency, location, size, and associated fracture patterns. METHODS: Skeletally mature patients presenting to a Level I trauma center from 2008-2018 with a tibial plateau fracture (AO/OTA 41B-C) were identified retrospectively. Fractures were classified by AO/OTA and Schatzker type. Radiographs and computed tomography (CT) scans were reviewed to identify and localize medial sided articular impaction. The location and surface area of impaction was characterized by creating frequency diagram heat maps from axial CT scans. Descriptive statistics were performed using standard measures. RESULTS: Of the 1032 tibial plateau fractures included, 82 (7.9%) were noted to have medial sided articular impaction. Rate of impaction varied by fracture type (p = 0.03): Schatzker II, 2% (7 of 381); Schatzker IV, 21% (19 of 96); and Schatzker VI, 11% (56 of 524). Average total surface area of impaction was 9% of the total and 19% of the medial plateau area. Area of impaction varied by fracture type (p = 0.004): Schatzker II, 6% (95% confidence interval [CI], 4%-7%); Schatzker IV, 11% (95% CI, 9%-13%), and Schatzker VI, 9% (95% CI, 7%-11%). The area of impaction occurred primarily along the lateral aspect of the medial plateau in Schatzker II fractures, in the anteromedial quadrant of Schatzker IV fractures, and was evenly distributed across the medial plateau in Schatzker VI fractures. CONCLUSIONS: Surgeons should be aware that medial articular impaction is present in approximately 8% of tibial plateau fractures. Schatzker IV fractures are most likely to have medial impaction and a larger proportion of the joint surface involved in these injuries.

Do Fully Threaded Transiliac-Transsacral Screws Improve Mechanical Stability of Vertically Unstable Pelvic Fractures? A Cadaveric Biomechanical Analysis.

OBJECTIVE: To determine whether fully threaded transiliac-transsacral (TI-TS) fixation is biomechanically superior to partially threaded TI-TS fixation of vertically unstable transforaminal sacral fractures. METHODS: Vertically unstable zone 2 sacral fractures were created in 20 human cadaveric pelves with a unilateral osteotomy and resection of 1 cm of bone through the foramen of the sacrum to represent comminution. Ten specimens received either 2 7.3-mm fully threaded or 2 7.3-mm partially threaded TI-TS screw fixation at the S1 and S2 body, and every specimen received standard 3.5-mm 8-hole parasymphyseal plating anteriorly. Each pelvis was loaded to 250 N at 3 Hz for 100,000 cycles and then loaded to failure. The primary outcome was fracture displacement at the S1 foramen, which was measured at 25,000, 50,000, 75,000, and 100,000 cycles. Secondary outcomes were simulated clinical failure of ≥1 cm displacement at the S1 foramen to determine occurrence probability of failure, and load at failure was defined as 2.5 cm of the linear loading system displacement. Specimens in the fully threaded and partially threaded cohorts were otherwise respectively comparable in regards to age, gender, and bone density. RESULTS: Five of the 10 TI-TS partially threaded specimens experienced simulated clinical failure with >1 cm displacement at the S1 foramen compared with 0 of the 10 TI-TS fully threaded cohort (50% vs. 0%, P = 0.03). The mean maximal displacement at the S1 foramen was greater in the partially threaded cohort (9.3 mm) compared with the fully threaded cohort (3.6 mm; P = 0.004). Fully threaded specimens also demonstrated greater mean force to failure than the partially threaded specimens (461 N vs. 288 N; P = 0.0001). CONCLUSIONS: Fully threaded TI-TS screw fixation seems to be mechanically superior to partially threaded fixation in a cadaveric vertically unstable transforaminal sacral fracture model with significantly less displacement of the posterior pelvic ring and greater load to failure.

Analysis of Computed Tomography-Based Technique for Measuring Femoral Anteversion: Implications for Measuring Rotation After Femoral Intramedullary Nail Insertion.

OBJECTIVES: To assess the reliability of the current computed tomography (CT)-based technique for determining femoral anteversion and quantify the prevalence and magnitude of side-to-side differences. DESIGN: Cross-sectional cohort study. SETTING: Academic trauma center. PATIENTS: We reviewed CT scans from 120 patients with bilateral full-length axial cuts of both femurs. Two hundred forty femurs with no fractures or other identifying features in their femora were included. Ten unique data sets were created to measure anteversion of the left and right sides. MAIN OUTCOME MEASUREMENTS: Intraobserver and interobserver reliability were calculated using intraclass correlation coefficients (ICCs) and pooled absolute differences. The mean absolute difference between the sides was determined using a fixed-effects model. RESULTS: Interobserver reliability was high (ICC: 0.85, 95% confidence interval [CI]: 0.83-0.88). The pooled mean absolute magnitude of variation between reviewers was small at 1.6 degrees (95% CI: 1.4-1.8 degrees) per scan. The intraobserver reproducibility was high (ICC: 0.91, 95% CI: 0.88-0.93) with a mean error of 2.7 degrees (95% CI: 2.2-3.1 degrees) per repeat viewing of the same scan by the same person. The magnitude of side-to-side variation was 2.0 degrees (95% CI: 1.5-2.6 degrees). Twenty-one subjects (18%, 95% CI: 12%-25%) had a mean side-to-side calculated femoral anteversion difference of ≥10 degrees, whereas 6 (5%, 95% CI: 2-10) subjects had a calculated mean side-to-side difference of ≥15 degrees. CONCLUSIONS: CT based femoral anteversion measurement techniques demonstrate good precision. Only 1 in 20 patients had side-to-side differences of 15 degrees or more.

Provisional Minifragment Plate Fixation of Acetabular Fractures-A Technical Trick.

SUMMARY: Acetabular fractures may not always be amenable to classic clamp-assisted reductions and interfragmentary lag screw fixation. The routine clamp-assisted reductions with limited osseous territory availability can inhibit typical 3.5-mm reconstruction plate application. Provisional minifragment plate fixation of these fracture patterns with subsequent clamp removal allows for definitive plate application. The provisional minifragment plates may also be retained to theoretically augment fixation. The authors present a step-by-step technique and clinical series of 57 patients demonstrating provisional minifragment fixation of elementary (n = 8) and associated (n = 49) acetabular fractures.

Complex Proximal Tibia Fractures: Workup, Surgical Approaches, and Definitive Treatment Options.

Proximal tibia fractures including intra-articular plateau fractures are complex injuries that benefit from an algorithmic approach in terms of treatment to optimize outcomes and minimize complications. Certainly, nonsurgical treatment will be an option for some injuries; however, this chapter will focus on those injuries best addressed with surgicalsurgical treatment. Indications for surgical treatment include joint incongruity, joint instability and limb malalignment. In regard to surgical treatment, important considerations include appropriate management of the soft-tissue envelope, staged provisional reduction and stabilization versus immediate definitive fixation, single versus multiple surgical approaches, unilateral versus bicondylar fixation, and treatment of concomitant fracture-dislocation. This chapter describes surgical approaches to the proximal tibia ranging from the standard anterolateral to complex dual approaches or posterior approaches. Soft-tissue management becomes important due to the high-energy nature of these injuries with trauma both at the time of injury and then the surgical insult. Learning to identify and minimize these risks as well as addressing the soft-tissue defects that may require treatment is highlighted. Implant selection and fixation options for bicondylar plateau fractures will be discussed. Finally, use of nails, especially suprapatellar nails for proximal extra-articular proximal tibia fractures is described.

Management of Pelvic Fractures.

Pelvic fractures are often the result of high-energy trauma and can result in significant morbidity. Initial management is focused on patient resuscitation and stabilization given the potential for life-threatening hemorrhage that is associated with these injuries. Radiographic evaluation and classification of the pelvic injury guides initial management, provisional stabilization, and preoperative surgical planning. Definitive reduction and fixation of the posterior and anterior pelvic ring is sequentially performed to restore stability and allow for mobilization and healing. Open techniques are commonly used for the pubic symphysis and displaced anterior and posterior ring injuries for which an acceptable reduction is unable to be obtained with closed or indirect techniques. Percutaneous fixation has become increasingly more common for both the anterior and posterior ring and utilizes screw placement within the osseous fixation pathways of the pelvis.

Total Elbow Arthroplasty for Distal Humerus Fractures Provided Similar Outcomes When Performed as a Primary Procedure or After Failed Internal Fixation.

OBJECTIVES: To compare clinical and functional outcomes of total elbow arthroplasty (TEA) for distal humerus fractures (DHF) performed either as a primary procedure or after internal fixation. DESIGN: Retrospective, observational study. SETTING: Mayo Clinic, Rochester, MN (1998 through 2016). PATIENTS/PARTICIPANTS: Twenty-two TEA for acute DHF and 66 TEA after previous internal fixation. MAIN OUTCOME MEASUREMENTS: Primary outcome measures included the Mayo Elbow Performance Score and motion. Reoperation rates and complications were also compared. RESULTS: The mean time between internal fixation and arthroplasty was 7.3 years, and the main indications for conversion to TEA were nonunion (36%) and posttraumatic osteoarthritis (32%). There were female predominance (70%) and significant differences in age (74 years vs. 60 years, P < 0.0001) and tobacco use (0 vs. 23%; P = 0.02) between the primary and the salvage cohorts, respectively. Cohort demographics were otherwise comparable. TEA provided similar outcomes in both cohorts in terms of the Mayo Elbow Performance Score (acute 85, salvage 81, P = 0.32) and motion (acute 95/82/75 degrees, salvage 112/81/72 degrees in ulnohumeral/pronation/supination, P = 0.07/P = 0.85/P = 0.65). Reoperation rates were also similar (36% acute vs. 39% salvage, P = 1.00). Aseptic loosening (2 acute, 8 salvage) and deep infection (2 acute, 7 salvage) were the most common complications. CONCLUSIONS: The clinical outcomes and reoperation rates of TEA for DHF seem to be similar when performed as a primary procedure or as salvage after previous internal fixation. The benefit of avoiding elbow arthroplasty in the acute setting needs to be balanced with the potential for 2 surgical procedures if internal fixation was to be unsuccessful. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

High-energy Pediatric Scapula Fractures and Their Associated Injuries.

OBJECTIVES: The purpose of this study was to evaluate pediatric scapula fractures occurring in high-energy motorized vehicle accidents and their associated injury patterns in a pediatric patient population. METHODS: One thousand nine hundred sixty-eight pediatric patients who presented after either on-road or off-road motorized vehicle accidents between 1996 and 2015 were retrospectively reviewed. Thirty-eight patients were found to have scapula fractures and the remaining 1930 were identified as controls. RESULTS: A total of 39 scapula fractures occurred in 38 patients. The most common pattern was the AO/OTA 14-A3 (n=32), followed by 14-A2 (n=5), 14-B1 (n=1), and 14-C2 (n=1). Scapula fracture patients experienced higher rate of spine fractures (42% vs. 18%, P=0.001), skull fractures (26% vs. 12%, P=0.02), rib fractures (40% vs. 7.6%, P<0.0001), clavicle fractures (34% vs. 6%, P<0.0001), and upper extremity fractures (58% vs. 21%, P<0.0001) compared with controls. Scapula fracture patients had higher Injury Severity Scores (22.1 vs. 10.8, P<0.0001), thoracic injury (79% vs. 31%, P<0.0001), intracranial hemorrhage (32% vs. 15%, P=0.012), pneumothorax (55% vs. 8%, P<0.0001), and lung contusion (63% vs. 12%, P<0.0001). No difference in mortality was observed for scapula and control patients (5% vs. 2%, P=0.302). CONCLUSIONS: Pediatric scapula fractures were not associated with higher mortality rates in this series but were associated with significant morbidity as demonstrated by high rates of associated intracranial hemorrhage, skull fractures, thoracic injury, upper extremity fractures, and spine fractures compared with control patients. Surgeons who care for pediatric trauma patients should view scapula fractures as an indicator for more significant injuries. LEVEL OF EVIDENCE: Level III.

Short Versus Long Cephalomedullary Nails for Pertrochanteric Hip Fractures: A Randomized Prospective Study.

OBJECTIVE: To compare functional and clinical outcomes in patients with pertrochanteric hip fractures treated with either a short (SN) or long (LN) cephalomedullary nail. DESIGN: Prospective, randomized. SETTING: Clinical investigation was performed at the Mayo Clinic's Level 1 Trauma Center in Rochester, MN. PATIENTS/PARTICIPANTS: Two hundred twenty patients with intertrochanteric fractures were prospectively randomized to an SN or LN cohort. A total of 168 patients (SN, n = 80; LN, n = 88) had a mean follow-up of 13.9 months. Fifty-two patients did not meet the minimum 3-month follow-up. Demographics were comparable between the cohorts. MAIN OUTCOME MEASURES: The primary outcome measurement was functional outcome evaluated by Short Form (SF-36) and Harris Hip scores (HHS) at 3 months. Secondary outcomes included implant failure, peri-implant fracture, mortality, operative time, estimated blood loss, and reoperation. RESULTS: SN and LN cohorts were comparable in all aspects of the SF-36. There was a clinically insignificant difference in the HHS between cohorts. Patients treated in the SN cohort experienced shorter operative times but did not differ in tip-to-apex distance or subtrochanteric fracture extension. There was no difference in implant cutout, deep surgical site infection, or peri-implant fractures. CONCLUSIONS: Patients treated with SNs or LNs for pertrochanteric femur fractures experienced comparable functional outcomes as measured by SF-36 and HHS. When compared with the LN cohort, SN patients experienced no difference in peri-implant fracture or lag-screw cutout and tolerated up to 3 cm of subtrochanteric fracture line extension. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Comparison of outcomes between axial radial and axial ulnar carpal injuries.

Axial carpal injuries are rare entities where a traumatic force transmits through the intermetacarpal space, dissociating the carpometacarpal joint and disrupting the distal carpal row in an axial radial or axial ulnar pattern via true axial force or compressive crush mechanism. Differences in outcomes remain unclear with regard to the specific type of axial carpal injury pattern. A retrospective case series identified 37 wrists (in 37 patients) over 25 years who presented to a Level 1 trauma centre, with 20 wrists experiencing an axial radial injury and 17 wrists experiencing an axial ulnar injury. Of all the variables evaluated, only axial radial injuries were identified as predictors of poor outcome as defined by Mayo Wrist scores with univariate analysis demonstrating 6 times increased risk and multivariate analysis demonstrating 15 times increased risk of a poor outcome compared with axial ulnar injuries. This knowledge will provide prognostic information to surgeons managing patients with these severe injuries. LEVEL OF EVIDENCE: IV.

Pediatric Orthopaedic Trauma and Associated Injuries of Snowmobile, ATV, and Dirtbike Accidents: A 19-Year Experience at a Level 1 Pediatric Trauma Center.

OBJECTIVES: The purpose of this study was to evaluate the type and severity of orthopaedic and associated injuries for snowmobile, All-terrain vehicles (ATV) and motorized dirtbike accidents in a pediatric patient population. METHODS: A total of 758 patients who presented following either snowmobile (n=87), ATV-related (n=308) or dirtbike (n=363)-related trauma at our institution between 1996 and 2015 were retrospectively reviewed. RESULTS: A total of 441 axial and appendicular fractures occurred requiring 533 procedures. Snowmobile and dirtbike accidents were associated with a higher rate of fractures (63%, 64%) than the ATV group (50%) (P=0.0008). Snowmobile injuries had the highest rate of spinal (23%) and lower extremity fractures (53%) (P=0.0004). Snowmobile and dirtbike cohorts had higher rate of femur fractures (22%, 17%, P=0.001) whereas the ATV cohort had higher rates of upper extremity (18%), hand (11%), scapula (4.6%), and open fractures (28.6%) (P<0.01). Head trauma was the most commonly associated injury in 275 patients with the highest rate in the ATV group (44%) who also had the highest rate of no helmet use (76%). Snowmobile and ATV patients had higher Injury Severity Score (11.3, 9.6) than dirtbike patients (7.8) (P=0.001). ATV patients were found to be younger (11.8 y) compared with snowmobile (13.2 y) and dirtbike (13.5 y) (P<0.01). CONCLUSIONS: Pediatric snowmobile, ATV and dirtbike accidents result in severe orthopaedic and associated injuries with each vehicle demonstrating significantly different injury patterns. Injury prevention should focus on improved safety mechanisms, protective gear, safe areas for off-road vehicle use and strict laws with minimum age requirements LEVEL OF EVIDENCE:: Level IV.

Osteosynthesis of AO/OTA 13-C3 distal humeral fractures in patients older than 70 years.

OBJECTIVE: The purpose of this retrospective case series was to examine the AO Foundation and Orthopaedic Trauma Association (AO/OTA) 13-C3 distal humeral fractures treated with open reduction-internal fixation (ORIF) in patients older than 70 years. METHODS: During an 8-year period, 21 patients older than 70 years with AO/OTA 13-C3 distal humeral fractures were treated with ORIF performed by 2 senior upper extremity traumatologists. There were 16 patients with >1 year of follow-up, with a mean age of 78 (70-84) years. RESULTS: At a mean follow-up of 4 years (1-8 years), all 16 patients demonstrated radiographic signs of bone union. Three patients underwent reoperations, including irrigation and débridement for postoperative infections (n = 2) and removal of implant for symptomatic olecranon intramedullary screw (n = 1). The mean postoperative total arc of ulnohumeral motion was 97° (80°-145°), including a mean flexion of 117° (106°-126°) and flexion contracture of 20° (14°-26°). The mean pronation was 69° (55°-85°), and supination was 78° (74°-9°0). The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 19 (standard deviation, 6.9; confidence interval, 15.4-22.8), and the mean Mayo Elbow Performance Score was 91 (standard deviation, 8.2; confidence interval, 86-95). CONCLUSIONS: ORIF remains a reliable option for treatment of AO/OTA 13-C3 distal humeral fractures in elderly patients. Excellent clinical outcomes can be achieved with preservation of motion and arm function through anatomic reduction, rigid internal fixation, and early mobilization.

NOS1AP genetic variation is associated with impaired healing of diabetic foot ulcers and diminished response to healing of circulating stem/progenitor cells.

It is unclear why many with diabetes develop foot ulcers (DFU) and why some do not heal. It could be associated with genetic variation. We have previously shown that NOS1AP variation is associated with lower extremity amputation in those with diabetes and that circulating stem progenitor cell concentration (SPC) is associated with impaired foot ulcer healing in those with diabetes. The goal of this study was to determine if NOS1AP variation is associated with impaired wound healing and with SPC mobilization in those with DFU. In longitudinal cohort study we demonstrate that NOS1AP variants rs16849113 and rs19649113 are associated with impaired wound healing and with SPC mobilization in those with DFU. We believe that further study of NOS1AP is merited and that it NOS1AP might be associated with a functional impairment.