Detecting Chronic Post-Traumatic Osteomyelitis of Mouse Tibia via an IL-13Rα2 Targeted Metallofullerene Magnetic Resonance Imaging Probe.

Differential diagnosis of chronic post-traumatic osteomyelitis (CPO) from aseptic inflammation remains challenging, since both pathological processes share similar clinical symptoms. Here we utilized a novel targeted metallofullerene nanoparticle based magnetic resonance imaging (MRI) probe IL-13-TAMRA-Gd3N@C80(OH)30(CH2CH2COOH)20 to detect CPO in mouse tibia via overexpressed IL-13Rα2 receptors. The functionalized metallofullerene was characterized by X-ray photoelectron spectroscopy. Upon lipopolysaccharide (LPS) stimulation, macrophage Raw 264.7 cells showed elevated IL-13Rα2 expression via immunofluorescence staining and increased MRI probe binding via built-in TAMRA fluorescence imaging. Trauma was induced in both tibia of mice and bacteria soaked suture was inserted into the right tibia to initiate infection. During the acute phase (1.5 weeks), luminol-bioluminescence imaging revealed much higher myeloperoxidase activity in the infected tibia compared to the sham. In the chronic phase (4 weeks), X-ray radiography illustrated bone deformation in the infected tibia compared to the sham. With T1 weighted sequences, the probe clearly exhibited hyperintensity in the infection foci at both acute and chronic phases, which was not observed in the sham tibia. Histological analysis revealed severe bone structural destruction and massive inflammatory cell infiltration in the infected tibia. Immunohistochemistry confirmed abundant expression of IL-13Rα2 in the infection site. In summary, we developed a noninvasive imaging approach to detect and differentiate CPO from aseptic inflammation using a new IL-13Rα2 targeted metallofullerene MRI probe. In addition, for the first time, IL-13Rα2 was investigated as a unique biomarker in the context of osteomyelitis. Our data established a foundation for the translational application of this MRI probe in the clinical differentiation of CPO.

Use of Computed Tomography Angiography to Predict Complications in Tibia Fractures: A Multicenter Retrospective Analysis.

OBJECTIVES: To assess the ability of computed tomography angiography identified infrapopliteal vascular injury to predict complications in tibia fractures that do not require vascular surgical intervention. DESIGN: Multicenter retrospective review. SETTING: Six Level I trauma centers. PATIENTS AND INTERVENTION: Two hundred seventy-four patients with tibia fractures (OTA/AO 42 or 43) who underwent computed tomography angiography maintained a clinically perfused foot not requiring vascular surgical intervention and were treated with an intramedullary nail. Patients were grouped by the number of vessels below the trifurcation that were injured. MAIN OUTCOME MEASUREMENTS: Rates of superficial and deep infection, amputation, unplanned reoperation to promote bone healing (nonunion), and any unplanned reoperation. RESULTS: There were 142 fractures in the control (no-injury) group, 87 in the one-vessel injury group, and 45 in the two-vessel injury group. Average follow-up was 2 years. Significantly higher rates of nerve injury and flap coverage after wound breakdown were observed in the two-vessel injury group. The two-vessel injury group had higher rates of deep infection (35.6% vs. 16.9%, P = 0.030) and unplanned reoperation to promote bone healing (44.4% vs. 23.9%, P = 0.019) compared with controls, as well as increased rates of any unplanned reoperation compared with control and one-vessel injury groups (71.1% vs. 39.4% and 51.7%, P < 0.001), respectively. There were no significant differences in rates of superficial infection or amputation. CONCLUSIONS: Tibia fractures with two-vessel injuries were associated with higher rates of deep infection and unplanned reoperation to promote bone healing compared with those without vascular injury, as well as increased rates of any unplanned reoperation compared with controls and fractures with one-vessel injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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

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

Intramedullary nailing of extra-articular distal tibial fractures.

AIMS: The aim of this study was to determine the immediate post-fixation stability of a distal tibial fracture fixed with an intramedullary nail using a biomechanical model. This was used as a surrogate for immediate weight-bearing postoperatively. The goal was to help inform postoperative protocols. METHODS: A biomechanical model of distal metaphyseal tibial fractures was created using a fourth-generation composite bone model. Three fracture patterns were tested: spiral, oblique, and multifragmented. Each fracture extended to within 4 cm to 5 cm of the plafond. The models were nearly-anatomically reduced and stabilized with an intramedullary nail and three distal locking screws. Cyclic loading was performed to simulate normal gait. Loading was completed in compression at 3,000 N at 1 Hz for a total of 70,000 cycles. Displacement (shortening, coronal and sagittal angulation) was measured at regular intervals. RESULTS: The spiral and oblique fracture patterns withstood simulated weight-bearing with minimal displacement. The multifragmented model had early implant failure with breaking of the distal locking screws. The spiral fracture model shortened by a mean of 0.3 mm (SD 0.2), and developed a mean coronal angulation of 2.0° (SD 1.9°) and a mean sagittal angulation of 1.2° (SD 1.1°). On average, 88% of the shortening, 74% of the change in coronal alignment, and 75% of the change in sagittal alignment occurred in the first 2,500 cycles. No late acceleration of displacement was noted. The oblique fracture model shortened by a mean of 0.2 mm (SD 0.1) and developed a mean coronal angulation of 2.4° (SD 1.6°) and a mean sagittal angulation of 2.6° (SD 1.4°). On average, 44% of the shortening, 39% of the change in coronal alignment, and 79% of the change in sagittal alignment occurred in the first 2,500 cycles. No late acceleration of displacement was noted. CONCLUSION: For spiral and oblique fracture patterns, simulated weight-bearing resulted in a clinically acceptable degree of displacement. Most displacement occurred early in the test period, and the rate of displacement decreased over time. Based on this model, we offer evidence that early weight-bearing appears safe for well reduced oblique and spiral fractures, but not in multifragmented patterns that have poor bone contact. Cite this article: Bone Joint J 2021;103-B(2):294-298.

A Locked Sacroiliac Joint Dislocation Requiring Open Reduction: A Case Report.

CASE: Vertically unstable pelvic ring injuries are often associated with sacroiliac (SI) joint subluxations or dislocations. The following report describes an irreducible SI joint dislocation where the ilium was locked in a position superior to the sacrum. This injury was refractory to initial closed reduction techniques and ultimately required an open reduction. CONCLUSIONS: This report demonstrates the limitations of closed manipulation for some vertically unstable pelvic ring injuries. It is critical to have a strong understanding of the anatomy and typical manipulations to succeed in both closed and open SI joint reduction attempts.

Understanding and Perception of Overlapping Surgery in an Orthopaedic Trauma Population: A Survey Study.

INTRODUCTION: Recently, overlapping surgery has received attention on the national scale. This study quantifies orthopaedic trauma patients' familiarity and concern with overlapping surgery as it relates to their care. METHODS: A 15-question survey was voluntarily completed by 200 orthopaedic trauma patients in the outpatient setting of a level I trauma center. Three domains were evaluated in the survey: demographic data, familiarity with overlapping surgery, and the degree of concern with overlapping surgery. Patients read a position statement explaining the practice of overlapping surgery, and their changes in level of concern were evaluated. Descriptive statistics were used to evaluate the data. RESULTS: A total of 200 patients completed the survey, of which 98 (49%) were male. The age range was broadly distributed. After surgery, 124 patients (62%) were seen for follow up. The remaining 76 patients (38%) did not undergo surgery. Regarding the practice of overlapping surgery, 116 respondents (58%) had no knowledge. There were 127 patients (63%) who reported their concern level as a 1 on an ordinal scale from 1 to 5, corresponding to the lowest possible level. Overall, 182 patients (91%) reported a level of concern of 3 (the median) or less with an average score of 1.7, indicating a low average level of concern. Six patients (3%) reported the maximum level of concern. On the whole, 160 patients (80%) reported either a decreased level of concern or no change after reading our department's position statement on overlapping surgery. Of the 124 patients, 81 (65%) postoperatively reported that they perceived no effect by overlapping surgery. The most common factors cited as areas of concern by patients were the absence of attending physician in the operating room (26%), risk of error by the resident (34%), and risk of a missed step in the surgical procedure (31%). CONCLUSION: These data indicate that most respondents had no previous knowledge of overlapping surgery and had a generally low level of concern with its use as practiced at our institution. Disclosing the use of overlapping surgery and its purpose to patients is an important component of preoperative counseling. LEVEL OF EVIDENCE: Level V.

Does external fixator pin site distance from definitive implant affect infection rate in pilon fractures?

INTRODUCTION: Tibial pilon fractures are often treated with initial external fixation followed by delayed definitive fixation. It has been postulated that the external fixator pin site may correlate with infection risk. The purpose of this study was to determine whether external fixator pin-site distance from definitive implants impacts the risk of deep infection in pilon fractures. MATERIALS AND METHODS: A retrospective cohort study was completed at a single level 1 trauma center. All patients ages 15-65 who underwent open reduction and internal fixation (ORIF) of a distal tibial fracture (AO/OTA Classification 43) from 2007 to 2013 were included. The final study population was 133 patients. The impact of external fixation pin location (relative to the definitive implant location) on postoperative infection was measured. RESULTS: As a continuous variable, the distance between the closest pin site and plate was 62.1 ± 44.1 mm in the infected cohort and 62.2 ± 49.7 mm in the non-infected cohort (p = 0.991). Further analysis was performed by grouping the distances into less than 0 mm (i.e. overlapping), >0.0 - 25.0 mm, >25.0 - 50.0 mm, >50.0 - 75.0 mm, >75.0 - 100.0 mm, and >100.0 mm of separation. No significant differences were noted with regards to the risk for infection. CONCLUSIONS: Staged care has been shown to be an effective treatment strategy for AO/OTA type 43 fractures. There are many variables to consider when placing an external fixator construct. In this cohort, pin site distance from definitive implant location was not associated with an increase in deep infections. LEVEL OF EVIDENCE: Level III.

Death After Jail Release.

The period immediately after release from prison or jail carries increased mortality risk. This study sought to better understand postrelease death by matching electronic health records from those incarcerated in New York City jails between 2011 and 2012 with vital statistics records. The in-jail and 6-week postrelease mortality rates were estimated to be 1.39 and 5.89 per 1,000 person-years, respectively. Of 59 deaths occurring within 6 weeks of release from jail, the causes included opioid overdose (37.3%), other drugs (8.5%), chronic disease (25.4%), assaultive trauma (20.3%), and other trauma (8.5%). These data confirm that overdose death accounts for the most frequent cause of postrelease death. Matching between correctional health systems and vital statistics can inform quality improvement efforts in jail health care delivery.

The use of ultrasound in evaluating orthopaedic trauma patients.

Musculoskeletal ultrasound is a low-cost, noninvasive method of evaluating orthopaedic trauma patients. It is particularly useful for patients with metallic hardware, which may degrade computed tomography or magnetic resonance images. Ultrasound has been used to evaluate fracture union and nonunion, infection, ligamentous injury, nerve compression, and mechanical impingement caused by hardware. Real-time dynamic examination allows identification of pathology and provides direct correlation between symptoms and the observed pathology.

Novel fixation method of a periprosthetic fracture of the acetabulum using burr holes through the retained cup for locking screw fixation.

The incidence of periprosthetic fractures of the acetabulum associated with a total hip arthroplasty is relatively low but may be increasing. Treatment options depend upon the stability of the prosthesis. In this case, we report an unusual fracture pattern where a large portion of posterior column remained osseointegrated to a displaced uncemented acetabular component and removal of the cup would have resulted in massive structural bone loss and potential pelvic discontinuity. A metal cutting burr was used to create additional screw holes in the cup to allow us to retain the original implant and also obtain fixation of the fracture. The patient had a good outcome at one year with a healed fracture, stable implant, and excellent function. To our knowledge, this technique has not been previously described and offers surgeons an approach to fix these challenging fractures.

Applications of Local Antibiotics in Orthopedic Trauma.

Local antibiotics have a role in orthopedic trauma for both infection prophylaxis and treatment. They provide the advantage of high local antibiotic concentration without excessive systemic levels. Nonabsorbable polymethylmethacrylate (PMMA) is a popular antibiotic carrier, but absorbable options including bone graft, bone graft substitutes, and polymers have gained acceptance. Simple aqueous antibiotic solutions continue to be investigated and appear to be clinically effective. For established infections, such as osteomyelitis, a combination of surgical debridement with local and systemic antibiotics seems to represent the most effective treatment at this time. Further investigation of more effective local antibiotic utilization is ongoing.

Whole-body Response for Pedestrian Impact with a Generic Sedan Buck.

To serve as tools for assessing injury risk, the biofidelity of whole-body pedestrian impact dummies should be validated against reference data from full-scale pedestrian impact tests. To facilitate such evaluations, a simplified generic vehicle-buck has been recently developed that is designed to have characteristics representative of a generic small sedan. Three 40 km/h pedestrian-impact tests have been performed, wherein Post Mortem Human Surrogates (PMHS) were struck laterally in a mid-gait stance by the buck. Corridors for select trajectory measures derived from these tests have been published previously. The goal of this study is to act as a companion dataset to that study, describing the head velocities, body region accelerations (head, spine, pelvis, lower extremities), angular velocities, and buck interaction forces, and injuries observed during those tests. Scaled, transformed head accelerations exceeded 80 g prior to head contact with the windshield for two of the three tests. Head xaxis angular velocity exceeded 40 rad/s prior to head contact for all three tests. In all cases the peak resultant head velocity relative to the vehicle was greater than the initial impact speed of the vehicle. Corridors of resultant head velocity relative to the vehicle were also developed, bounded by the velocities observed in these tests combined with those predicted to occur if the PMHS necks were perfectly rigid. These results, along with the other kinematic and kinetic data presented, provide a resource for future pedestrian dummy development and evaluation.

Successful treatment of osseous blastomycosis without pulmonary or disseminated disease and review of the literature.

Blastomycosis commonly occurs following inhalation of Blastomyces dermatitidis conidia causing a pulmonary infection and can disseminate to extrapulmonary sites. Osseous involvement primarily results from hematogenous spread, but in rare cases, direct inoculation can occur. We describe a case of osseous blastomycosis without pulmonary or disseminated disease successfully treated with posaconazole.

Locked versus unlocked plating with respect to plate length in an ulna fracture model.

OBJECTIVE: Determine contributions of plate length and locked fixation in an ulna fracture. METHODS: two groups of six pairs of ulnae were plated with a small-fragment LCP around a 1 cm ostectomy. Control specimens: eight-hole plate, three consecutive unlocked screws on each side. Experimental specimens: 10-hole plate, two screws (Group 1, Unlocked; Group 2, Locked) in near- far configuration on either side. OUTCOMES: Stiffness in torsion and 4-point bending stiffness and load at yield. RESULTS: Unlocked: mean torsional stiffness (Ncm/deg) for the experimental and control specimens, 7.57 and 7.73, respectively (p > 0.05); mean bending stiffness (kN/m), 88.50 and 90.76, respectively (p > 0.05); and mean yield strength (kN), 1.06 and 0.89, respectively (p < 0.05). Locked: mean torsional stiffness for the experimental and control specimens, 7.10 and 8.27, re- spectively (p > 0.05); mean bending stiffness, 72.96 and 79.20, respectively (p > 0.05); and mean yield strength, 1.23 and 1.03, respectively (p > 0.05). Mean differences between the experimental and control specimens in tor- sion: Unlocked, 0.17; Locked, 1.17 (p > 0.05). Mean differences in bending stiffness: Unlocked, 2.25; Locked, 6.24 (p > 0.05). Mean differences in yield strength: Unlocked, 0.17; Locked, 0.21 (p > 0.05). CONCLUSIONS: Locked plating provided no mechanical advantage over unlocked plating. The use of a longer plate with unlocked screws increased yield strength.

Depression and quality of life issues in patients with amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a progressive motor neuron disease that usually results in death secondary to respiratory failure. The psychological reaction to the diagnosis of ALS in patient and caregiver has received increasing attention. Reports are highly variable as to the severity of depressive symptoms in patients with ALS. When they exist, depressive symptoms can be managed with pharmacologic interventions. Recognizing cognitive impairment is essential in the management of patients with ALS. Quality of life assessments have been used to further evaluate the reaction to the disease. Maintaining a meaningful quality of life centers on psychological, supportive, and spiritual factors, as opposed to physical status. In addition to the patient's reaction, there are a variety of responses experienced by caregivers. Clinicians should provide appropriate support to the caregivers of the patients during the course of the illness and after death.

Noncompliance in neurologic patients.

Patient compliance is essential for optimal therapeutic outcome. However, medical noncompliance remains a significant issue in the treatment of many neurologic disorders. Neurologic patients are particularly vulnerable to poor treatment adherence. The chronic and often relapsing and remitting course of neurologic illness creates challenges in maintaining treatment compliance. In addition, comorbid psychiatric conditions can contribute to noncompliance. Decreasing the complexity of dosing schedules, addressing side effect concerns, recognizing financial impact of treatment, and addressing comorbid psychiatric illness all can help to improve compliance. Potentially, the most effective methods to improve compliance include improving the doctor patient relationship, increasing a patient's social support system, and maximizing patient education.

Psychiatric manifestations of autoimmune disorders.

Psychiatric symptoms are common to many autoimmune disorders. Patients often will have mood disorders, anxiety, cognitive deficits, delirium, and psychosis. These symptoms may reflect the direct or indirect effect of the autoimmune disorder on the central nervous system, may be related to medications used to treat the disorder, or may be a direct psychologic impact from suffering with the autoimmune disorder. Accurately recognizing the psychiatric component and generating a differential diagnosis is a complex task for the treating physician. Treatment of the psychiatric component to the disorder often will include addressing steroid induced side effects, psychotropic medications, psychotherapy, patient and family education, and a strong physician-patient relationship.

Does preejaculatory penile secretion originating from Cowper's gland contain sperm?

PURPOSE: To determine if spermatozoa are present in the preejaculatory penile secretion, originating from Cowper's gland. DESIGN: Prospective clinical and laboratory study. SETTING: Andrology and Sex Counseling Unit, Department of Obstetrics and Gynecology, Academic Teaching Hospital. PATIENTS: Five patients referred for premature ejaculation, three for excessive fluid secreted during foreplay and four normal healthy volunteers. INTERVENTION: Glass slide smears of preejaculatory Cowper's gland secretion obtained during foreplay from at least two different occasions, and semen samples after masturbation. MAIN OUTCOME MEASURES: Microscopic examination of air-dried smears, and routine semen analyses. RESULTS: None of the preejaculatory samples contained sperm. All the patients had sperm in routine sperm analyses. CONCLUSIONS: Preejaculatory fluid secreted at the tip of the urethra from Cowper's gland during sexual stimulation did not contain sperm and therefore cannot be responsible for pregnancies during coitus interruptus.

Organization of hospital medical care of mass casualties in peace time disasters

The organization of a civilian hospital for the reception and treatment of mass disaster casualties is described(AU)