Exploring the Potential of a Smart Ring to Predict Postoperative Pain Outcomes in Orthopedic Surgery Patients.

Poor pain alleviation remains a problem following orthopedic surgery, leading to prolonged recovery time, increased morbidity, and prolonged opioid use after hospitalization. Wearable device data, collected during postsurgical recovery, may help ameliorate poor pain alleviation because a patient's physiological state during the recovery process may be inferred from sensor data. In this study, we collected smart ring data from 37 inpatients following orthopedic surgery and developed machine learning models to predict if a patient had postsurgical poor pain alleviation. Machine learning models based on the smart ring data were able to predict if a patient had poor pain alleviation during their hospital stay with an accuracy of 70.0%, an F1-score of 0.769, and an area under the receiver operating characteristics curve of 0.762 on an independent test dataset. These values were similar to performance metrics from existing models that rely on static, preoperative patient factors. Our results provide preliminary evidence that wearable device data may help control pain after orthopedic surgery by incorporating real-time, objective estimates of a patient's pain during recovery.

Identification of subtle residual sacroiliac joint flexion and extension malreductions in AO/OTA 61-C1.2 (APC3) pelvic injuries after provisional anterior ring reduction.

PURPOSE: Hemipelvis reduction in the setting of AO/OTA 61-C1.2 (APC3) pelvic injuries can be challenging. A common strategy is to provisionally reduce or fix the anterior ring prior to definitive fixation of the posterior ring. In this scenario, it is difficult to assess whether residual sacroiliac joint (SIJ) widening is due to hemipelvis flexion/extension or lateral displacement. This simulation sought to identify a radiographic marker for posterior ilium flexion or extension malreduction in the setting of a reduced anterior ring. METHODS: Symphyseal and both anterior and posterior SIJ ligaments were cut in 8 cadaveric pelvis. The symphysis was reduced and wired. One centimeter of posterior flexion or extension at the SIJ was created to mimic the clinical scenario of hemipelvis flexion or extension malreduction, and a lateral compressive force was applied. SIJ widening and the direction of anterior or posterior ileal displacement relative to the contralateral joint were assessed via inlet views. SIJ widening and the direction of cranial or caudal ileal displacement were assessed using outlet views. Comparisons between flexion and extension models used Fisher's exact test. RESULTS: On outlet views, all flexed hemipelvis demonstrated caudal ileal translation at the superior SIJ, in contrast to all extended hemipelvis demonstrated cranial translation (p < 0.0005); the scenarios were easily distinguishable. Conversely, inlet imaging was unable to identify the direction of malreduction. Flexion/extension scenarios resulted in similar amounts of SIJ widening. CONCLUSION: Residual flexion and extension hemipelvis malreductions in APC3 injuries after provisional anterior fixation can be differentiated by the direction of ileal displacement at the superior SIJ on the outlet view.

Fluoroscopic images of the sacroiliac joint alone are unable to identify simulated flexion or extension malreduction of the anterior pelvic ring in AO/OTA 61-B2.3 pelvic injuries.

PURPOSE: Reduction of AO/OTA 61-B2.3 (APC2) pelvic fractures is challenging in the setting of anterior ring comminution. The anterior ring is visually much simpler to evaluate for flexion or extension hemipelvis deformity than the posterior ring, except in the setting of comminution, necessitating some other visual reference to judge hemipelvis reduction. We sought to test whether pelvic inlet and outlet fluoroscopy of the contours of the sacroiliac joint could be used in isolation to judge hemipelvis flexion or extension. METHODS: Symphyseal and anterior SIJ ligaments were cut (6 cadaveric pelvis). The symphysis was held malreduced to produce one centimeter flexion and extension deformity: 1 cm was selected to mimic a maximum clinical scenario. The SIJ was assessed using inlet and outlet fluoroscopy. The scaled width of the SIJ was assessed at the joint apertures and midjoint on both inlet and outlet views. Joint widths in flexion and extension were compared against joint widths measured on the reduced SIJ using paired t-tests. RESULTS: There was no statistical difference in the superior (p = 0.227, 0.675), middle (p = 0.203, 0.693), and inferior (p = 0.232, 0.961) SIJ widths between hemipelvis flexion or extension models against reduced SIJ on outlet views. There was no statistical difference in the anterior (p = 0.731, 0.662), middle (p = 0.257, 0.655), and posterior (p = 0.657, 0.363) SIJ widths between flexion or extension models against reduced SIJ on inlet views. CONCLUSION: Inspection of SIJ width on inlet and outlet fluoroscopy cannot detect up to one centimeter of hemipelvis flexion or extension malreduction in the setting of AO/OTA 61-B2.3 (APC2) pelvic fractures with complex anterior injuries.

Inpatient pain alleviation after orthopaedic trauma surgery-are we doing a good job?

PURPOSE: Poor pain alleviation (PPA) after orthopaedic surgery is known to increase recovery time, readmissions, patient dissatisfaction, and lead to chronic postsurgical pain. This study's goal was to identify the magnitude of PPA and its risk factors in the orthopaedic trauma patient population. METHODS: A single-institution's electronic medical records from 2015 to 2018 were available for retrospective analysis. Inclusion criteria included orthopaedic fracture surgery patients admitted to the hospital for 24 h or more. Collected variables included surgery type, basic demographics, comorbidities, inpatient medications, pain scores, and length of stay. PPA was defined as a pain score of ≥ 8 on at least three occasions 4-12 h apart. Associations between collected variables and PPA were derived using a multivariable logistic regression model and expressed in adjusted odds ratios. RESULTS: A total of 1663 patients underwent fracture surgeries from 2015 to 2018, and 25% of them reported PPA. Female sex, previous use of narcotics, increased ASA, increased baseline pain score, and younger age without comorbidities were identified as significant risk factors for PPA. Spine procedures were associated with increased risk of PPA, while procedures in the hip, shoulder, and knee had reduced risk. Patients experiencing PPA were less likely to receive NSAIDs compared to other pain medications. CONCLUSIONS: This study found an unacceptably high rate of PPA after fracture surgery. While the identified risk factors for PPA were all non-modifiable, our results highlight the necessity to improve application of current multimodal approaches to pain alleviation including a more personalized approach to pain alleviation.

Frailty and comorbidity predict 30 day postoperative outcomes, independent of anatomical site of fracture.

INTRODUCTION: Fragility fractures are a major threat to geriatric patients. However, it is unclear whether this patient population's inherent frailty and comorbidity or the physiologic insult caused by the fracture and its surgery contribute more to undesirable patient outcomes. Hence, this study examines if frailty and comorbidity can predict 30 day postoperative outcomes while the effects of multiple fracture sites are accounted for. METHODS: A retrospective review of patients ≥ 65 years of age in the National Surgical Quality Improvement Program who underwent surgical treatment between 2013 and 2017 was performed. A total of 52,497 patients were included in the final analysis, including fracture cases of the extremities, limbs, and hip. Demographics, several metrics of preoperative health, temporal variables, and fracture location were tested in bivariate analysis of 30 day postoperative mortality, length of stay in hospital, discharge outcome, and complications. Significant variables were considered for multivariate logistic regression models for each outcome. RESULTS: Frailty, comorbidity, and time to surgery were found to be the significant predictors in multivariate analysis of each 30 day postoperative outcome, independent of the effects of fracture site (p < 0.05). Examination of 30 day mortality found that American Society of Anesthesiologists Class ≥ 3 (2.30 Odds Ratio), modified Frailty Index > 0 (1.37 OR), Charleston Comorbidity Index ≥ 6 (1.63 OR), and time to surgery (1.45 OR) were especially important (all p < 0.05). Additionally, the worst outcomes were associated with fractures of the pelvis/hip and femur/knee, including 30 day mortality (5.90 and 5.12 OR, respectively; both p < 0.05). CONCLUSION: The effects of the preoperative health were found to be independent of patient demographics and fracture site. Additionally, specific high-risk fracture sites are significant predictors of outcome, supporting the need to prioritize these patients. Clinical care pathways for geriatric patients may benefit from emphasis on these high-risk fractures and preoperative patient health.

Physiologic Motion in the Intact and Unstable Syndesmosis During Plantigrade Weightbearing in Controlled Ankle Motion Boots.

Consensus has not been reached for the optimal postoperative care after high ankle sprain and syndesmotic fixation. A potential drawback of earlier return to activity is greater instability of the ankle and fixation failure. The controlled ankle motion (CAM) boot has been an effective implementation to stabilize the leg and may aid in safe early weightbearing status. However, there is insufficient study of its effect on motion in the syndesmosis following injury. Hence, the aim of this cadaveric study was to determine the stability of the ankle with a CAM boot at 3 levels of injury: syndesmosis ligaments intact (no injury), syndesmosis ligaments cut, and syndesmosis and fibula cut. Six cadaveric legs were subjected to each level of injury and axially loaded at 1 Hz between 100 N-1.5 times body weight for 50 seconds, and axial force, axial displacement, and optical tracking data were recorded. It was found that the ankle, when protected by the CAM boot, maintained syndesmosis motion with no difference (p > .05) from the uninjured state, regardless of syndesmotic ligament and fibular injury. This finding was consistent across anterior-posterior, medial-lateral, and superior-inferior axes. Overall, our study may suggest that early weightbearing with a CAM boot maintains a physiologically range of motion in the syndesmosis.

"Bring Your Own Device"-A New Approach to Wearable Outcome Assessment in Trauma.

Background and Objectives: Outcome data from wearable devices are increasingly used in both research and clinics. Traditionally, a dedicated device is chosen for a given study or clinical application to collect outcome data as soon as the patient is included in a study or undergoes a procedure. The current study introduces a new measurement strategy, whereby patients' own devices are utilized, allowing for both a pre-injury baseline measure and ability to show achievable results. Materials and Methods: Patients with a pre-existing musculoskeletal injury of the upper and lower extremity were included in this exploratory, proof-of-concept study. They were followed up for a minimum of 6 weeks after injury, and their wearable outcome data (from a smartphone and/or a body-worn sensor) were continuously acquired during this period. A descriptive analysis of the screening characteristics and the observed and achievable outcome patterns was performed. Results: A total of 432 patients was continuously screened for the study, and their screening was analyzed. The highest success rate for successful inclusion was in younger patients. Forty-eight patients were included in the analysis. The most prevalent outcome was step count. Three distinctive activity data patterns were observed: patients recovering, patients with slow or no recovery, and patients needing additional measures to determine treatment outcomes. Conclusions: Measuring outcomes in trauma patients with the Bring Your Own Device (BYOD) strategy is feasible. With this approach, patients were able to provide continuous activity data without any dedicated equipment given to them. The measurement technique is especially suited to particular patient groups. Our study's screening log and inclusion characteristics can help inform future studies wishing to employ the BYOD design.

Comparison of fibula strut and calcium phosphate cement augmentation of the medial buttress in 2-part proximal humerus fractures reconstruction: a biomechanical study.

PURPOSE: Augmentation strategies for surgical fixation of proximal humerus fractures (PHF) are available to address their relatively high failure rate. The purpose of this study was to compare two medial-buttress augmentation strategies for PHF fixation. METHODS: A two-part PHF model with loss of medial buttress was created in 16 synthetic bones. The PHFs were fixed with locking plates and either calcium phosphate cement (CPC) or fibula strut (FS) augmentation. After cadaveric validations, the fixation constructs were subjected to nondestructive axial compression tests, followed by a cyclic test. Construct stiffness and angular displacement of the humerus head were recorded. RESULTS: Humeral head angular displacement was statistically greater in the CPC group than in the FS group at the applied force of 300 N and higher (p < 0.05). Axial stiffness was statistically greater in the FS fixation group than in the CPC group at initial and final phases of cyclic loading protocol (p < 0.05). CONCLUSIONS: In an osteoporotic cadaveric model of a 2-part PHF with loss of a medial buttress, locked plate constructs augmented with FS have a higher resistance to varus collapse compared to those augmented with CPC.

Wireless Measurements Using Electrical Impedance Spectroscopy to Monitor Fracture Healing.

There is an unmet need for improved, clinically relevant methods to longitudinally quantify bone healing during fracture care. Here we develop a smart bone plate to wirelessly monitor healing utilizing electrical impedance spectroscopy (EIS) to provide real-time data on tissue composition within the fracture callus. To validate our technology, we created a 1-mm rabbit tibial defect and fixed the bone with a standard veterinary plate modified with a custom-designed housing that included two impedance sensors capable of wireless transmission. Impedance magnitude and phase measurements were transmitted every 48 h for up to 10 weeks. Bone healing was assessed by X-ray, µCT, and histology. Our results indicated the sensors successfully incorporated into the fracture callus and did not impede repair. Electrical impedance, resistance, and reactance increased steadily from weeks 3 to 7-corresponding to the transition from hematoma to cartilage to bone within the fracture gap-then plateaued as the bone began to consolidate. These three electrical readings significantly correlated with traditional measurements of bone healing and successfully distinguished between union and not-healed fractures, with the strongest relationship found with impedance magnitude. These results suggest that our EIS smart bone plate can provide continuous and highly sensitive quantitative tissue measurements throughout the course of fracture healing to better guide personalized clinical care.

Simulation enabled search for explanatory mechanisms of the fracture healing process.

A significant portion of bone fractures fail to heal properly, increasing healthcare costs. Advances in fracture management have slowed because translation barriers have limited generation of mechanism-based explanations for the healing process. When uncertainties are numerous, analogical modeling can be an effective strategy for developing plausible explanations of complex phenomena. We demonstrate the feasibility of engineering analogical models in software to facilitate discovery of biomimetic explanations for how fracture healing may progress. Concrete analogical models-Callus Analogs-were created using the MASON simulation toolkit. We designated a Target Region initial state within a characteristic tissue section of mouse tibia fracture at day-7 and posited a corresponding day-10 Target Region final state. The goal was to discover a coarse-grain analog mechanism that would enable the discretized initial state to transform itself into the corresponding Target Region final state, thereby providing an alternative way to study the healing process. One of nine quasi-autonomous Tissue Unit types is assigned to each grid space, which maps to an 80×80 µm region of the tissue section. All Tissue Units have an opportunity each time step to act based on individualized logic, probabilities, and information about adjacent neighbors. Action causes transition from one Tissue Unit type to another, and simulation through several thousand time steps generates a coarse-grain analog-a theory-of the healing process. We prespecified a minimum measure of success: simulated and actual Target Region states achieve ≥ 70% Similarity. We used an iterative refinement protocol to explore many combinations of Tissue Unit logic and action constraints. Workflows progressed through four stages of analog mechanisms. Similarities of 73-90% were achieved for Mechanisms 2-4. The range of Upper-Level similarities increased to 83-94% when we allowed for uncertainty about two Tissue Unit designations. We have demonstrated how Callus Analog experiments provide domain experts with a fresh medium and tools for thinking about and understanding the fracture healing process.

Resection Arthroplasty Compared With Total Hip Arthroplasty in Treating Chronic Hip Pain of Patients With a History of Substance Abuse.

BACKGROUND: Retrospective comparison of surgical management of severe hip pain in patients with a history of substance abuse treated by modified Girdlestone resection arthroplasty (RA) vs delayed total hip arthroplasty (THA) following yearlong sobriety pathway. METHODS: Patients were identified using charts, current procedural terminology (CPT) code query, and THA sobriety pathway registry. The primary outcome was adequate pain control following surgery, defined as visual analog scale ≤ 5 or verbal description of "moderate" or lower pain. RA patients with infectious arthritis were analyzed separately. The secondary outcome was the level of mobility after surgery. RESULTS: In the THA pathway, 15 of 28 (53.6%) proved sobriety, 11 (39.3%) underwent THA, and 9 (32.1%) achieved adequate pain control (median 77 days). After RA, 19 (76%) achieved adequate pain control (median 119.5 days). Preoperative infection did not significantly affect time to pain control after RA (P = .94). Time to adequate pain control was not significantly different between RA and THA patients (P = .19). Three patients (30%) experienced improved level of mobility after THA and 7 (70%) experienced no change. After RA, 7 patients (29.1%) experienced improved level of mobility, 3 (13.6%) lost mobility, and 14 (63.6%) experienced no change. Three RA patients were later converted to THA without complication. CONCLUSION: Yearlong sobriety pathway leading to THA leads to successful pain control in less than one-third of enrolled patients. Compared to delayed THA, RA enables more patients with substance abuse to be treated sooner and results in successful reduction of pain in a similar proportion of patients. RA may be an effective pain-reducing procedure for these patients.

Effect of varus and valgus alignment on implant loading after proximal femur fracture fixation.

INTRODUCTION: More than 10 % of proximal femur fractures repaired with either a sliding hip screw and side plate (SHS-P) or a sliding hip screw and intramedullary nail (SHS-IMN) demonstrate varus malreduction. The purpose of this study was to compare the effect of varus or valgus loading on comminuted intertrochanteric fractures repaired with SHS-P or SHS-IMN constructs. METHODS: Unstable intertrochanteric fractures with segmental comminution were generated in 12 cadaver proximal femurs, six of which were fixed with an SHS-P and six with an SHS-IMN. Both implants had a strain gauge at the lag screw-nail-plate interface to assess implant load bearing. The load on the implants was measured with the specimens in neutral position and at 5°, 10°, and 15° of varus and valgus. RESULTS: Loads on both SHS-IMN and SHS-P constructs were significantly increased when loading the implants in varus and significantly decreased when loading the implants in valgus. Unlike the SHS-IMN, the SHS-P trended toward increased load bearing at 15° varus (159.1 vs. 118.5 %, P = .065) and trended toward less load bearing at 15° valgus (42.3 vs. 59.8 %, P = .06). CONCLUSIONS: Regardless of implant choice, avoiding varus loading on the fixation construct reduces the load on the implant. SHS-P constructs may be more affected by varus or valgus malalignment than SHS-IMN constructs.

Time intervals in the treatment of fractured femurs as indicators of the quality of trauma systems.

OBJECTIVE: To investigate the use of time intervals in the treatment of fractured femurs as indicators of the quality of trauma systems. METHODS: Time intervals from injury to admission, admission to surgery and surgery to discharge for patients with isolated femur fractures in four low- and middle-income countries were compared with the corresponding values from one German hospital, an Israeli hospital and the National Trauma Data Bank of the United States of America by means of Student's t-tests. The correlations between the time intervals recorded in a country and that country's expenditure on health and gross domestic product (GDP) were also evaluated using Pearson's product moment correlation coefficient. FINDINGS: Relative to patients from high-income countries, those from low- and middle-income countries were significantly more likely to be male and to have been treated by open femoral nailing, and their intervals from injury to admission, admission to surgery and surgery to discharge were significantly longer. Strong negative correlations were detected between the interval from injury to admission and government expenditure on health, and between the interval from admission to surgery and the per capita values for total expenditure on health, government expenditure on health and GDP. Strong positive correlations were detected between the interval from surgery to discharge and general government expenditure on health. CONCLUSION: The time intervals for the treatment of femur fractures are relatively long in low- and middle-income countries, can easily be measured, and are highly correlated with accessible and quantifiable country data on health and economics.

Nonphysician Evaluators and Recording-Based Tools in Surgical Skill Assessment: A Feasibility Study.

OBJECTIVES: To investigate the feasibility of nonmedically trained evaluators and image- and video-based tools in the assessment of surgical skills in a key orthopedic procedure. DESIGN: Orthopedic surgeons at varying skill levels were evaluated by their ability to repair a cadaveric bi-malleolar ankle fracture. Nonphysician viewers and expert orthopedic surgeons independently scored video recordings and fluoroscopy images of the procedure through Global Rating Scales (GRS) and procedure-specific checklist tools. Statistical analysis was used to determine if the evaluators and assessment tools were able to differentiate skill level. SETTING: An academic tertiary care hospital. PARTICIPANTS: The surgical procedure was completed by 3 orthopedic residents, 3 orthopedic trauma fellows, and 4 orthopedic trauma attending surgeons. The procedure was independently evaluated by 2 orthopedic surgeons and 2 nonphysicians. RESULTS: Operating participants were stratified by ≤ or >10 bimalleolar ankle fracture cases performed alone (inexperienced, n = 5 vs experienced, n = 5). Expert surgeon viewers could effectively stratify skill group through the GRS for video and fluoroscopy analysis (p < 0.05), and the video procedure-specific checklist (p < 0.05), but not the fluoroscopy procedure-specific checklist. Nonphysician viewers generally recognized skill groupings, although with less separation than surgeon viewers. These evaluators performed the best when aided by video and fluoroscopy procedure-specific checklists. Meanwhile, breakdowns of each tool into critical zones for improvement and evaluator-independent metrics such as case experience, self-reported confidence, and surgical time also indicated some skill differentiation. CONCLUSIONS: The feasibility of using video recordings and fluoroscopic imaging based surgical skills assessment tools in orthopedic trauma was demonstrated. The tools highlighted in this study are applicable to both cadaver laboratory settings and live surgeries. The degree of training that is required by the evaluators and the utility of measuring surgical times of specific tasks should be the subject of future studies.

Prolonged Opioid Use Is Associated With Poor Pain Alleviation After Orthopaedic Surgery.

INTRODUCTION: Severe pain after orthopaedic surgery is common and often results in chronic postsurgical pain and chronic opioid use (COU). Poor pain alleviation (PPA) after surgery is a well-described modifiable risk factor of COU. Although PPA's role in inducing COU is recognized in other areas, it is not well defined in orthopaedic surgery. The aim of this study was to evaluate the influence of PPA on COU in the population who underwent orthopaedic surgery. METHODS: Medical records from a large academic medical center from 2015 to 2018 were available for analysis. Patients undergoing nononcologic surgical procedures by the orthopaedic surgery service that also required at least 24 hours of hospital stay for pain control were included in the study. Surgery type, body location, basic demographics, preoperative opioid use, comorbidities, medications administered in the hospital, opioid prescription after discharge, and length of stay were recorded. COU was defined as a continued opioid prescription at ≥ 3 months, ≥ 6 months, or ≥ 9 months after surgery. PPA was defined as having a recorded pain score of eight or more, between 4 and 12 hours apart, three times during the hospital stay. RESULTS: A total of 7,001 patients were identified. The overall rate of COU was 25.3% at 3 months after surgery. Charlson Comorbidity Index > 0 and PPA were statistically significant predictors of opioid use at all time points. Preoperative opioid naivety was associated with decreased COU. The type and location of surgical procedures were not associated with COU, after controlling for baseline variables. CONCLUSION: Our findings demonstrated an overall high rate of COU. The known risk factors of COU were evident in our study population, particularly the modifiable risk factor of acute postsurgical PPA. Better management of postsurgical pain in orthopaedic patients may lead to a decrease in the rates of COU in this group.

Wearable activity data can predict functional recovery after musculoskeletal injury: Feasibility of a machine learning approach.

Delayed functional recovery after injury is associated with significant personal and socioeconomic burden. Identification of patients at risk for a prolonged recovery after a musculoskeletal injury is thus of high relevance. The aim of the current study was to show the feasibility of using a machine learning assisted model to predict functional recovery based on the pre- and immediate post injury patient activity as measured with wearable systems in trauma patients. Patients with a pre-existing wearable (smartphone and/or body-worn sensor), data availability of at least 7 days prior to their injury, and any musculoskeletal injury of the upper or lower extremity were included in this study. Patient age, sex, injured extremity, time off work and step count as activity data were recorded continuously both pre- and post-injury. Descriptive statistics were performed and a logistic regression machine learning model was used to predict the patient's functional recovery status after 6 weeks based on their pre- and post-injury activity characteristics. Overall 38 patients (7 upper extremity, 24 lower extremity, 5 pelvis, 2 combined) were included in this proof-of-concept study. The average follow-up with available wearable data was 85.4 days. Based on the activity data, a predictive model was constructed to determine the likelihood of having a recovery of at least 50 % of the pre-injury activity state by post injury week 6. Based on the individual activity by week 3 a predictive accuracy of over 80 % was achieved on an independent test set (F1=0,82; AUC=0,86; ACC=8,83). The employed model is feasible to assess the principal risk for a slower recovery based on readily available personal wearable activity data. The model has the potential to identify patients requiring additional aftercare attention early during the treatment course, thus optimizing return to the pre-injury status through focused interventions. Additional patient data is needed to adapt the model to more specifically focus on different fracture entities and patient groups.

Wearable Sensors in Other Medical Domains with Application Potential for Orthopedic Trauma Surgery-A Narrative Review.

The use of wearable technology is steadily increasing. In orthopedic trauma surgery, where the musculoskeletal system is directly affected, focus has been directed towards assessing aspects of physical functioning, activity behavior, and mobility/disability. This includes sensors and algorithms to monitor real-world walking speed, daily step counts, ground reaction forces, or range of motion. Several specific reviews have focused on this domain. In other medical fields, wearable sensors and algorithms to monitor digital biometrics have been used with a focus on domain-specific health aspects such as heart rate, sleep, blood oxygen saturation, or fall risk. This review explores the most common clinical and research use cases of wearable sensors in other medical domains and, from it, derives suggestions for the meaningful transfer and application in an orthopedic trauma context.

Acute complications of patients with pelvic fractures after pelvic angiographic embolization.

BACKGROUND: Hemodynamically unstable patients with a pelvic fracture and arterial pelvic bleeding frequently are treated with pelvic angiographic embolization (PAE). PAE is reported to be a safe and effective method of controlling hemorrhage. However, the loss of blood supply and subsequent ischemia from embolization may lead to adverse consequences. OBJECTIVES/PURPOSES: We sought to determine (1) the frequency and types of complications observed after PAE; (2) the mortality after PAE; and (3) the clinical factors associated with complications and mortality after PAE. METHODS: We conducted a retrospective case series descriptive study at a Level I trauma center. Using our institution's trauma registry, we isolated patients with pelvic fractures treated with PAE admitted between June 1999 and December 2007. Complications attributed to PAE occurring in the initial hospital stay were recorded. We identified 98 patients with pelvic fractures treated by PAE with an average hospital stay of 25.3 days. RESULTS: The complication rate was 11% and included six patients with gluteal muscle necrosis (6%), five with surgical wound breakdown (5%), four deep infections (4%), one superficial infection, two patients with of impotence (2%), and one with bladder necrosis. The mortality rate in the PAE group reached 20%. Bilateral embolization was performed in 100% of the patients with complications. Nonselective embolization was performed in 81% of patients with complications. All of the patients with gluteal necrosis had bilateral nonselective embolization. CONCLUSIONS: Bilateral or nonselective PAE is associated with significant complications during the initial hospital stay. The value of PAE should be weighed against its possible adverse consequences. Selective unilateral arterial embolization should be considered whenever possible.

The treatment of acquired patella baja with proximalize the tibial tuberosity.

PURPOSE: Acquired patella baja may result in decreased range of motion of the knee, extensor lag, and anterior knee pain. The aim of the study was to evaluate the efficacy of tibial tubercle osteotomy with proximal displacement. METHODS: Between 1998 and 2011, a proximalization of the tibial tuberosity was performed in 15 patients (15 knees) with patella baja diagnosed using the Blackburne-Peel ratio. Clinical outcomes included the Tegner Lysholm knee scoring scales, the WOMAC questionnaire, the short form-12 (SF-12), and a visual analogue score (VAS) pain scale. RESULTS: Fifteen proximalizations of the tibial tuberosity were performed, with a mean follow-up period of 64 months (5-160). The mean patient age was 59 years (41-86 years). The mean preoperative Blackburne-Peel ratio of 0.4 (0.1-0.6) was improved to a mean of 1.0 (0.8-1.2) post-operatively, which was associated with significant improvements in the Lysholm knee scoring scale from 13.3 ± 13.0 to 86.7 ± 10.4 points (p < 0.0001). Quality of life, as measured using the SF-12 outcome, also improved significantly (p < 0.0001), as did all WOMAC questionnaire score subscales (p < 0.0001). The VAS preoperative status for pain improved from 8.3 ± 2.0 to 1.5 ± 1.8. No patient had delayed or non-union of the osteotomy site. CONCLUSIONS: A series of patients with patella baja, treated with proximalization of the tibial tuberosity, achieved satisfactory outcomes in terms of pain relief and improved function, without major complication.