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BACKGROUND: There is significant variability both in how proximal humerus fractures (PHFs) are treated and the ensuing patient outcomes. The purpose of this study was to investigate which surgeon- and patient-specific factors contribute to decision-making in the treatment of adult PHFs. We hypothesized that orthopedic sub-specialty training creates inherent bias and plays an important role in management algorithms for PHFs. METHODS: We performed a prospective cohort investigation in 2 groups of surgeons-traumatologists (N = 25) and shoulder & elbow/sports surgeons (SES) (N = 26)-and asked them to provide treatment recommendations for 30 distinct clinical cases with standardized radiographic and clinical data. This is a population-based sample of surgeons who take trauma call and treat PHFs with different sub-specializations and practice settings including academic, hospital-employed, and private. Surgeons characterized based on subspecialty (trauma vs. SES), experience level (>10 vs. ≤10-years), and employment type (hospital- vs. non-hospital-employed). Chi-square analyses, logistic mixed-effects modeling, and relative importance analysis were used to evaluate the data. RESULTS: Of the patient-specific factors, we found that the management of PHFs is largely dependent on initial radiographs obtained. Traumatologists were more likely to offer open reduction internal fixation (ORIF) and less likely to offer arthroplasty: 69% ORIF (traumatologists) vs. 51% ORIF (SES, P < .001), 8% arthroplasty (traumatologists) vs. 17% (SES, P < .001). Traumatologists were less likely to change from operative (either ORIF or arthroplasty) to non-operative management compared to SES surgeons when presented with additional patient demographic data. Surgeon-specific factors contributed to more than one-half of the variability in decision-making of PHF management while patient-specific factors contributed to about one-third of the variability in decision-making. CONCLUSIONS: As physicians strive to advance the treatment for PHFs and optimize patient outcomes, our findings highlight the complex overlap between surgeon-, fracture-, and patient-specific factors in the final decision-making process.
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Fraturas do Úmero , Ortopedia , Fraturas do Ombro , Cirurgiões , Adulto , Humanos , Estudos Prospectivos , Fixação Interna de Fraturas , Fraturas do Ombro/diagnóstico por imagem , Fraturas do Ombro/cirurgia , Resultado do Tratamento , Úmero/cirurgia , Estudos RetrospectivosRESUMO
The modern management of open fractures was established after the foundational work of Gustilo and Anderson, but we continue to strive to determine the optimal treatment of open fractures to diminish the risk of infection. The ideal timing of antibiotics, presentation to the operating room, and timing of procedures such as flap coverage continue to be investigated with incremental changes recommended over the years. This article aims to provide the most recent review of the literature regarding the timing and management of both upper and lower extremity open fractures, pediatric open fractures, current topics of controversy, and the data supporting current treatment recommendations.
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BACKGROUND: The aim of the study is to investigate the differences between the extensile lateral (EL) and sinus tarsi (ST) approaches for the treatment of displaced intra-articular calcaneus fractures as treated by a single surgeon. METHODS: A retrospective cohort study performed at a Level 1 trauma center. One hundred twenty-nine consecutive intra-articular calcaneus fractures from 2011 to 2018 that were surgically treated by a single surgeon. Primary outcomes were time to surgery, operative time, postoperative restoration of the critical angle of Gissane, postoperative wound complications, and need for unplanned re-operation. RESULTS: Patient characteristics, including demographics, mechanism of injury, and fracture patterns were similar between the EL and ST approach groups. There was a significant decrease in unplanned secondary procedures (P = .008), shorter time to definitive fixation (P = .00001), and shorter average operative time in the ST group (P = .00001). Postoperative measurement of the critical angle of Gissane between the two groups was significantly different, but minute with an average difference of approximately 3 degrees (P = .025). Measurements in both groups were within the expected range of normal. CONCLUSIONS: For displaced intra-articular calcaneus fractures, a limited open ST approach is associated with a significant reduction in the time to definitive fixation and decreased operative time. The EL approach was associated with a small, but significant improvement in the restoration of the critical angle of Gissane compared with the ST approach. Therefore, an ST approach may allow for earlier surgical intervention and result in equivalent quality of reduction compared with an EL approach. LEVEL OF EVIDENCE: Level III.
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INTRODUCTION: It is our hypothesis that physician-specific variables affect the management of distal radius (DR) fractures in addition to patient-specific factors. METHODS: A prospective cohort study was conducted evaluating treatment differences between Certificate of Additional Qualification hand surgeons (CAQh) and board-certified orthopaedic surgeons who treat patients at level 1 or level 2 trauma centers (non-CAQh). After institutional review board approval, 30 DR fractures were selected and classified (15 AO/OTA type A and B and 15 AO/OTA type C) to create a standardized patient data set. The patient-specific demographics and surgeon's information regarding the volume of DR fractures treated per year, practice setting, and years posttraining were obtained. Statistical analysis was done using chi-square analysis with a postanalysis regression model. RESULTS: A notable difference was observed between CAQh and non-CAQh surgeons. Surgeons in practice longer than 10 years or who treat >100 DR fractures/year were more likely to choose surgical intervention and obtain a preoperative CT scan. The two most influential factors in decision making were the patients' age and medical comorbidities, with physician-specific factors being the third most influential in medical decision making. DISCUSSION: Physician-specific variables have a notable effect on decision making and are critical for the development of consistent treatment algorithms for DR fractures.
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Cirurgiões , Fraturas do Punho , Humanos , Estudos Prospectivos , Algoritmos , Tomada de DecisõesRESUMO
OBJECTIVE: To correlate patient-specific and surgeon-specific factors with outcomes after operative management of distal intra-articular tibia fractures. DESIGN: Retrospective cohort study. SETTING: 3 Level 1 tertiary academic trauma centers. PATIENTS/PARTICIPANTS: The study included a consecutive series of 175 patients with OTA/AO 43-C pilon fractures. MAIN OUTCOME MEASUREMENTS: Primary outcomes included superficial and deep infection. Secondary outcomes included nonunion, loss of articular reduction, and implant removal. RESULTS: The following patient-specific factors correlated with poor surgical outcomes: increased age with superficial infection rate ( P < 0.05), smoking with rate of nonunion ( P < 0.05), and Charlson Comorbidity Index with loss of articular reduction ( P < 0.05). Each additional 10 minutes of operative time over 120 minutes was associated with increased odds of requiring I&D and any treatment for infection. The same linear effect was seen with the addition of each fibular plate. The number of approaches, type of approach, use of bone graft, and staging were not associated with infection outcomes. Each additional 10 minutes of operative time over 120 minutes was associated with an increased rate of implant removal, as did fibular plating. CONCLUSIONS: While many of the patient-specific factors that negatively affect surgical outcomes for pilon fractures may not be modifiable, surgeon-specific factors need to be carefully examined because these may be addressed. Pilon fracture fixation has evolved to increasingly use fragment-specific approaches applied with a staged approach. Although the number and type of approaches did not affect outcomes, longer operative time was associated with increased odds of infection, while additional fibular plate fixation was associated with higher odds of both infection and implant removal. Potential benefits of additional fixation should be weighed against operative time and associated risk of complications. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fraturas do Tornozelo , Fraturas da Tíbia , Humanos , Duração da Cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/cirurgia , Fraturas do Tornozelo/diagnóstico por imagem , Fraturas do Tornozelo/cirurgia , Fixação Interna de Fraturas/efeitos adversosRESUMO
INTRODUCTION: CT and three-dimensional (3D) CT reconstructions have been shown to improve the understanding of acetabular fractures. With the increased availability of 3D pelvic CT reconstructions, our goal for this study was to develop an algorithm to aid residents in the classification of acetabular fractures. We hypothesized that the use of a stepwise algorithm will markedly enhance the trainees' ability to correctly identify acetabular fracture patterns. METHODS: This was a multicenter study that included 33 residents. Residents reviewed 15 sets of 3D reconstructions of the 10 acetabular fracture patterns. Residents completed the first round, and the results were collected electronically. Three weeks later, they were asked to classify the fractures a second time with the use of the algorithm. The number of correct responses from the two sessions was analyzed to determine if the algorithm improved residents' ability to correctly classify fracture patterns. RESULTS: Thirty-three residents classified 15 fractures which yielded 495 unique responses. Residents correctly classified 52.5% (260/495) of fractures without the algorithm, which significantly increased to 77.5% (384/495) (P = 0.001) with the algorithm. When stratified by year in residency, all residents were able to correctly classify markedly more fractures with the algorithm. DISCUSSION: Overall, we believe this method is a reproducible diagnostic tool that will assist residents in classifying acetabular fractures. We were able to demonstrate that with the use of this algorithm, residents' ability to correctly classify acetabular fractures is markedly enhanced, regardless of year in training. This algorithm will be a useful adjunct to assist and advance trainees' education and understanding of a complex topic.
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Fraturas Ósseas , Fraturas do Quadril , Ortopedia , Acetábulo/diagnóstico por imagem , Algoritmos , Fraturas Ósseas/diagnóstico por imagem , Humanos , Tomografia Computadorizada por Raios XRESUMO
Cannabinoid compounds are being increasingly used as an analgesic adjuvant in the orthopedic population, but little data exist to either support or oppose this practice pattern. A review of all contemporary (2000-2020) studies on the use of cannabinoids in orthopedics is presented. Physicians and patients are optimistic that cannabinoids can decrease pain scores and perhaps opioid use; however, their application in orthopedics is not well characterized. In addition to the social stigma regarding the use of cannabis, there is limited high-quality evidence of the efficacy of cannabinoids in treating orthopedic-related pain. As cannabis becomes more accessible, well-designed trials are needed to better understand cannabinoids and guide orthopedic practice. [Orthopedics. 2022;45(6):e295-e302.].
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Canabinoides , Procedimentos Ortopédicos , Humanos , Canabinoides/uso terapêutico , Dor/tratamento farmacológico , Analgésicos/uso terapêutico , Procedimentos Ortopédicos/efeitos adversosRESUMO
BACKGROUND: It is unclear which pharmacological agents, and at what dosage and timing, are most effective for venous thromboembolism (VTE) prophylaxis in patients with pelvic/acetabular fractures. METHODS: We searched the Cochrane Database of Systematic Reviews, Embase, Web of Science, EBSCO, and PubMed on October 3, 2020, for English-language studies of VTE prophylaxis in patients with pelvic/acetabular fractures. We applied no date limits. We included studies that compared efficacy of pharmacological agents for VTE prophylaxis, timing of administration of such agents, and/or dosage of such agents. We recorded interventions, sample sizes, and VTE incidence, including deep vein thrombosis (DVT) and pulmonary embolism. RESULTS: Two studies (3604 patients) compared pharmacological agents, reporting that patients who received direct oral anticoagulants (DOACs) were less likely to develop DVT than those who received low molecular weight heparin (LMWH) (p < 0.01). Compared with unfractionated heparin (UH), LMWH was associated with lower odds of VTE (odds ratio [OR] = 0.37, 95% confidence interval [CI]: 0.22-0.63) and death (OR = 0.27, 95% CI: 0.10-0.72). Three studies (3107 patients) compared timing of VTE prophylaxis, reporting that late prophylaxis was associated with higher odds of VTE (OR = 1.9, 95% CI: 1.2-3.2) and death (OR = 4.0, 95% CI: 1.5-11) and higher rates of symptomatic DVT (9.2% vs. 2.5%, p = 0.03; and 22% vs. 3.1%, p = 0.01). One study (31 patients) investigated dosage of VTE prophylaxis, reporting that a higher proportion of patients with acetabular fractures were underdosed (23% of patients below range of anti-Factor Xa [aFXa] had acetabular fractures vs. 4.8% of patients within adequate range of aFXa, p<0.01). CONCLUSIONS: Early VTE chemoprophylaxis (within 24 or 48 h after injury) was better than late administration in terms of VTE and death. Many patients with acetabular fractures are underdosed with LMWH, with inadequate aFXa levels. Compared with UH, LMWH was associated with lower odds of VTE and death. DOACs were associated with lower risk of DVT compared with LMWH. LEVEL OF EVIDENCE: III, systematic review of retrospective cohort studies.
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Embolia Pulmonar , Tromboembolia Venosa , Anticoagulantes/uso terapêutico , Quimioprevenção , Heparina/uso terapêutico , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/prevenção & controle , Estudos Retrospectivos , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/prevenção & controleRESUMO
INTRODUCTION: Cannabinoids are an increasingly popular therapy among orthopaedic patients for musculoskeletal conditions. A paucity of evidence to support their use in orthopaedics exists, likely because of the incongruence of federal and state legalization and the stigma surrounding cannabis. The purpose of this study is to elucidate sentiments and knowledge base of the orthopaedic trauma community with regard to cannabinoid-containing compounds. METHODS: A 21-question online survey was distributed to the members of the Orthopaedic Trauma Association with a response window of 3 months. RESULTS: We evaluated 251 responses. Most (88%) of the respondents did not believe that they were knowledgeable about the mechanism of action of cannabis/cannabidiol (CBD) but did feel that cannabis or CBD products play a role in managing postoperative pain (73%). Most respondents did not believe that they would be stigmatized if they suggested CBD (83%) or cannabis (67%) to patients. Despite this, fewer respondents have suggested CBD (38%) or cannabis (29%) to their patients. CONCLUSIONS: Sentiment toward cannabinoids among orthopaedic traumatologists is remarkably favorable; however, in-depth understanding is admittedly poor and routine use is uncommon. More clinical research for cannabinoids is needed to help orthopaedic traumatologists provide guidance for patients seeking advice for this recently popular therapeutic.
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Canabidiol , Canabinoides , Cannabis , Alucinógenos , Ortopedia , HumanosRESUMO
BACKGROUND: Periprosthetic distal femur fractures (PPDFFs) present a challenge in terms of optimizing fixation in patients with poor bone quality and limited bone stock. The main treatment options include laterally based plating and intramedullary nailing. We hypothesized that treatment of PPDFFs with intramedullary nails would result in improved union rate, fewer complications, and an equivalent rate of malalignment compared to plating. MATERIALS AND METHODS: Cases of PPDFFs were identified through a query of our institutional trauma database between 2011-2018. Adult patients (>18 years) were included if they sustained a fracture of the distal femur around a total knee arthroplasty (TKA) that was not initially treated at another institution. The anatomic lateral distal femoral angle (aLDFA) and the anatomic posterior distal femoral angle (aPDFA) were measured on the follow-up radiographs. RESULTS: Ninety-seven PPDFFs in 97 patients, with a mean age of 76 years and 74% female were identified. Plating was used in 74 patients (76%) and 23 patients (24%) were treated with intramedullary nailing. Extension deformity in the sagittal plane was more common following intramedullary nailing compared to plating (10/23 nailing versus 10/74 plating) (p=0.002). There were 12 reoperations (12/75, 16%), and the method of fixation was not associated with rate of reoperation (p=0.9). CONCLUSION: Intramedullary nailing was associated with an increased risk of malalignment, most commonly an extension deformity, in this series. However, malalignment was not associated with worse outcomes.
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Artroplastia do Joelho , Fraturas do Fêmur , Fixação Intramedular de Fraturas , Fraturas Periprotéticas , Adulto , Idoso , Artroplastia do Joelho/efeitos adversos , Pinos Ortopédicos , Placas Ósseas , Feminino , Fraturas do Fêmur/diagnóstico por imagem , Fraturas do Fêmur/cirurgia , Fêmur , Humanos , Masculino , Fraturas Periprotéticas/diagnóstico por imagem , Fraturas Periprotéticas/cirurgia , Resultado do TratamentoRESUMO
INTRODUCTION: The goal of this study was to identify the current practices and rationale of orthopaedic surgeons regarding venous thromboembolism (VTE) prophylaxis for pelvic and acetabular (P&A) fractures. METHODS: A 25-item web-based questionnaire was made available to all Orthopaedic Trauma Association (OTA) members on the OTA website. Analysis of data was performed after the three-month study period. RESULTS: One hundred three active OTA members completed the survey. Most respondents practiced at an academic level I trauma centers. The most important factor in selecting a VTE regimen was its effectiveness, whereas cost was the least important. Low-molecular-weight heparin (LMWH) remains the preferred agent for VTE prophylaxis after P&A trauma. Factors such as surgical intervention and weight-bearing had a variable effect on surgeons' opinions regarding the type and duration of VTE prophylaxis. CONCLUSION: Most surgeons treating P&A fractures use LMWH for VTE prophylaxis, but the decision on which agent to use and duration of treatment is multifactorial. Published VTE prophylaxis literature and guidelines provide some guidance, but there is no consensus. Overall, LMWH appears to be the VTE prophylaxis agent of choice for most orthopaedic trauma surgeons, irrespective of nonsurgical or surgical management of these fractures.
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Acetábulo/lesões , Fraturas Ósseas/cirurgia , Heparina de Baixo Peso Molecular/administração & dosagem , Cirurgiões Ortopédicos , Ossos Pélvicos/lesões , Complicações Pós-Operatórias/prevenção & controle , Padrões de Prática Médica , Trombose Venosa/prevenção & controle , Fixação de Fratura/métodos , Humanos , Inquéritos e QuestionáriosRESUMO
INTRODUCTION: Obesity is an epidemic facing the United States affecting nearly 40% of the population (93.3 million adults). The objective of this study was to compare early perioperative complications in patients with a normal BMI to patients who are pre-obese, obese, and morbidly obese. MATERIALS AND METHODS: The study was conducted at a Level-I trauma center. Patients were separated into 4 groups based on their BMI. Group 1 had a BMI < 25 (normal), Group 2 had a BMI between 25-29.9 (pre-obesity), Group 3 had a BMI between 30-39.9 (obese), and Group 4 had a BMI ≥40 (morbidly obese). Outcome variables included total operative time (OT), estimated blood loss (EBL), length of stay (LOS), and early medical and surgical complications. A comparison between groups was performed for each outcome variable and surgical complication. RESULTS: We identified 333 patients and the number of patients in Groups 1-4 were 86, 96, 121, and 30, respectively. The average BMI for Groups 1-4 was 22.3, 27.3, 35.9, and 44.9, respectively (p < 0.001). OT, EBL, and LOS did not differ between groups or between the surgical approach utilized. There were no significant relationships when comparing complication rates between groups. Patients in Group 4 experienced significantly more PE compared to patients in Group 2 (p=0.01). Additionally, patients in Group 4 experienced a significantly more PE than patients in Groups 1 and 2 combined (p<.01). The relative risk of having a PE if BMI is ≥40, compared to a BMI <30 is 18.40 (95% CI = 1.98 - 171.13). The PEs were not fatal in all cases. CONCLUSIONS: In the treatment of the obese and morbidly obese with acetabular fractures, we find that these cohorts are not at a greater risk of wound complications or infection. The higher rate of pulmonary embolism seen in the morbidly obese should be considered when evaluating these patients for appropriate thromboembolic prophylaxis.
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Obesidade Mórbida , Adulto , Índice de Massa Corporal , Estudos de Coortes , Humanos , Tempo de Internação , Obesidade Mórbida/cirurgia , Complicações Pós-Operatórias , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: To report the clinical result of a series of patients who underwent acetabular fracture fixation using a Kocher-Langenbeck approach without a specialty traction table. DESIGN: Retrospective case series. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: All patients who sustained posterior wall or posterior wall associated acetabular fractures that were treated operatively with a Kocher-Langenbeck approach over a 5-year period. INTERVENTION: Surgical fixation of acetabular fractures using a flat, radiolucent table. MAIN OUTCOME MEASUREMENTS: Outcomes included reduction quality and complications such as infection, heterotopic ossification, loss of reduction or fixation, medical complications, and neurologic injury. RESULTS: We identified 172 patients. No articular malreductions of greater than 2 mm were noted on postoperative CT scans. There were 13 surgical complications observed (8.1%). There was 1 death in our cohort (0.6%), and 3 patients had nonfatal pulmonary emboli (1.9%). There were no nerve injuries observed. There were 6 acute infections (3.1%) requiring surgical intervention. Three patients had symptomatic heterotopic bone that required excision (1.9%). Four patients (2.5%) required eventual total hip arthroplasty. CONCLUSION: Overall, we report on the largest cohort in the literature undergoing a prone Kocher-Langenbeck without a specialty table for acetabular fracture fixation. We found that limited extremity prepping and draping for a prone Kocher-Langenbeck on a flat, radiolucent table did not result in an increased rate of postoperative neurological complications or malreductions of acetabular fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Fraturas Ósseas , Fraturas do Quadril , Acetábulo/diagnóstico por imagem , Acetábulo/cirurgia , Fixação Interna de Fraturas , Fraturas Ósseas/diagnóstico por imagem , Fraturas Ósseas/cirurgia , Fraturas do Quadril/diagnóstico por imagem , Fraturas do Quadril/cirurgia , Humanos , Estudos Retrospectivos , TraçãoRESUMO
OBJECTIVE: To determine whether intramedullary nail (IMN) size and its relation to the canal diameter [nail-canal (NC) diameter] impacts the union rate or time to union in the treatment of femoral shaft fractures. DESIGN: Retrospective review. SETTING: Two Level 1 and 1 Level 2 trauma centers. PATIENTS: Two hundred eighty-seven patients met the criteria and were included in the study. INTERVENTION: Patients were treated with either an antegrade or retrograde IMN. Comparisons were first performed comparing 10- versus 11- versus 13-mm nails. Patients were then divided into 3 groups based on the difference between the size of the femoral canal at the isthmus and the IMN (NC diameter). Group 1: <1.0 mm, group 2: >1.0 and <2.0 mm, and group 3: >2.0 mm. MAIN OUTCOME MEASUREMENTS: Nonunion rates, mean time to union. RESULTS: Two hundred eighty-seven patients with a minimum of 12-month follow-up, who were treated with size with IMN for femoral shaft fractures, were assessed for fracture characteristics, time to union, and union rate. When comparing IMN size, no statistical difference was found when comparing time to union or overall union rate. When comparing NC diameter, no significant difference was found in union rate and time to union when comparing between the groups. CONCLUSION: Similar rate of union and time to union were exhibited regardless of nail size or NC diameter. This can correlate to the standard utilization of a reamed, titanium 10-mm IMN with 5.0-mm interlocking screws in the treatment of femoral shaft fractures, offering potentially less reaming, shorter operative times, and removing unnecessary stock from inventory. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fraturas do Fêmur , Fixação Intramedular de Fraturas , Pinos Ortopédicos , Fraturas do Fêmur/diagnóstico por imagem , Fraturas do Fêmur/cirurgia , Fêmur , Consolidação da Fratura , Humanos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: The purpose of this study was to determine the importance of factors considered by orthopaedic trauma fellowship applicants when evaluating programs. We hypothesized that applicants will prioritize consistent factors when applying to programs. In addition, we assessed how the applicants use the Internet to research potential fellowships. Our goal is to provide fellowships with information to optimize both their fellowship and online contents. METHODS: At the 2018 and 2019 Orthopaedic Trauma Association meetings, a paper survey was given to each attendee of multiple fellowships' informational sessions. The survey consisted of 25 factors that applicants may consider when evaluating fellowships ranked on a 1-to-5 Likert scale. Additional questions were asked to determine how applicants use the Internet and social media when researching fellowships. RESULTS: We received 111 surveys (roughly a 56% response rate). Ninety-eight applicants (88%) indicated that they use fellowship websites to research fellowships. The utilization of fellowship websites was markedly greater than the use of other online resources. The highest rated factors surveyed were surgical experience (mean 4.95; SD 0.26), pelvic and acetabular experience (4.80; 0.52), lower extremity fracture experience (4.75; 0.58), and current faculty at the fellowship (4.55; 0.78). The lowest rated factors were the ability to moonlight (2.04; 1.08), salary (1.88; 1.12), and spine trauma experience (1.45; 0.87). Surgical experience and pelvic/acetabular experience were rated markedly higher than every other factor surveyed. DISCUSSION: To our knowledge, this is the first study to demonstrate that most orthopaedic trauma fellowship applicants use fellowship websites when researching programs. Programs may use this study to optimize their fellowship experience to reflect what the applicants value. In addition, programs may use this study as a guide when updating their websites. Fellowships with informative websites that meaningfully highlight their fellowship experience may have a competitive edge in attracting applicants to their programs.
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Educação de Pós-Graduação em Medicina/métodos , Bolsas de Estudo , Internet , Internato e Residência , Ortopedia/educação , Avaliação de Programas e Projetos de Saúde , Feminino , Humanos , Masculino , Mídias Sociais , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: Periprosthetic fractures of the distal femur can be challenging injuries to treat; nonunion rates of up to 22% have been reported. The purpose of this study was to determine the rate of complications and nonunion in a multicenter series, and to identify patient or surgical factors that were associated with nonunion. DESIGN: Retrospective comparative study SETTING: Three Level 1 trauma centers PATIENTS: Fifty-five patients with a periprosthetic distal femur fracture proximal to a total knee arthroplasty. Minimum follow up for inclusion was six months or until union or failure. INTERVENTION: Surgical fixation using a precontoured lateral locking plate MAIN OUTCOME MEASUREMENT: Fracture union was the primary outcome. Patient demographic and injury variables (age, comorbidities, fracture classification and characteristics) and surgical technique factors (mode of plate fixation, plate material, working length, screw density, and proximal screw type) were identified and compared between patients who developed a nonunion and those who did not. Regression analysis was performed to identify independent risk factors for nonunion. RESULTS: The overall rate of nonunion was 18% and the total complication rate was 24%. After additional surgery, 49 of 55 patients went on to heal (89%). There were no statistical differences in patient demographic or injury variables between the union and nonunion groups, and none of the variables studied were independent risk factors for nonunion in the regression analysis. CONCLUSIONS: In this series of 55 patients with periprosthetic distal femur fractures treated with precontoured lateral locking plates, 18% developed nonunion and the overall complication rate was 24%. No patient or surgical variables were identified as risk factors. Future research should seek to identify patients at high risk for complication and nonunion who could benefit from alternative fixation strategies or distal femoral replacement.
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Fraturas do Fêmur , Fraturas Periprotéticas , Placas Ósseas , Fraturas do Fêmur/diagnóstico por imagem , Fraturas do Fêmur/cirurgia , Fêmur , Fixação Interna de Fraturas/efeitos adversos , Humanos , Fraturas Periprotéticas/diagnóstico por imagem , Fraturas Periprotéticas/epidemiologia , Fraturas Periprotéticas/cirurgia , Estudos RetrospectivosRESUMO
Carpal boss is a relatively uncommon cause of pain and swelling on the dorsum of the wrist and usually presents in adult patients. However, it is occasionally seen in adolescents. We describe an unusual case of a 15-year-old girl with a carpal boss treated surgically after failed conservative treatment. Surgical excision of the carpal boss resulted in relief of symptoms with no complications.
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Capitato/cirurgia , Articulações Carpometacarpais/cirurgia , Osteófito/cirurgia , Adolescente , Capitato/diagnóstico por imagem , Articulações Carpometacarpais/diagnóstico por imagem , Diagnóstico Diferencial , Feminino , Humanos , Osteófito/diagnóstico por imagem , Cuidados Pós-Operatórios , Tomografia Computadorizada por Raios XRESUMO
Alcohol is one of most commonly abused substances in the United States, and it has contributed to a growing epidemic of medical ailments, including cirrhosis, neurologic and psychosocial disorders, impairment to fertility, and cancer. Moreover, acute and chronic alcohol use represent a significant risk factor for orthopaedic injury and postoperative complications. Yet, relatively little is known about the clinical implications of alcohol abuse in common orthopaedic procedures. Acute withdrawal from alcohol is potentially fatal, particularly in the orthopaedic inpatient whose abstinence is mandated by the hospital setting. The aim of this review is to address the screening, diagnostic, and therapeutic tools available to appropriately manage acute alcohol withdrawal in the orthopaedic inpatient. The influence of chronic alcohol consumption on bone metabolism, fracture healing, and surgical fixation will also be reviewed because this information may guide surgical decision making.
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Consumo de Bebidas Alcoólicas/efeitos adversos , Alcoolismo/complicações , Procedimentos Ortopédicos/efeitos adversos , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/induzido quimicamente , Síndrome de Abstinência a Substâncias/complicações , Consumo de Bebidas Alcoólicas/terapia , Alcoolismo/terapia , Humanos , Complicações Pós-Operatórias/terapia , Fatores de Risco , Síndrome de Abstinência a Substâncias/terapiaRESUMO
Many studies have suggested the involvement of wild-type (wt) p53 in the repair of DNA double-strand breaks (DSBs) via DNA end-joining (EJ) process. To investigate this possibility, we compared the capacity and fidelity of DNA EJ in RKO cells containing wt p53 and RKO cells containing no p53 (RKO cells with p53 knockdown). The p53 knockdown cells showed lower fidelity of DNA EJ compared to the control RKO cells. The DNA end-protection assay revealed the association of a protein complex including heterogeneous nuclear ribonucleoprotein G (hnRNP G) with the DNA ends in RKO cells containing wt p53, but not with the DNA ends in RKO cells with p53 knockdown. Depletion of endogenous hnRNP G notably diminished the fidelity of EJ in RKO cells expressing wt p53. Moreover, an ectopic expression of hnRNP G significantly enhanced the fidelity of DNA EJ and the protection of DNA ends in human cancer cells lacking hnRNP G protein or containing mutant hnRNP G. Finally, using recombinant hnRNP G proteins, we demonstrated the hnRNP G protein is able to bind to and protect DNA ends from degradation of nucleases. Our results suggest that wt p53 modulates DNA DSB repair by, in part, inducing hnRNP G, and the ability of hnRNP G to bind and protect DNA ends may contribute its ability to promote the fidelity of DNA EJ.