INTRODUCTION:The Salter-Harris (S-H) classification establishes five types of physeal fractures and is the most widely used to describe them. However, the Peterson classification includes fracture patterns not covered by the S-H classification, such as fractures crossing the metaphysis and extending to the physis and open injuries with loss of physis. Nonetheless, it is necessary to validate and compare its reliability with that of the S-H to enhance diagnostic possibilities and clinical interpretation. This study aimed to compare the consistency of intra and interobserver agreement of the S-H and Peterson classifications. METHODS:A cross-sectional study was conducted to evaluate the reliability of 100 radiographs in the anteroposterior and lateral views. Five pediatric orthopedic surgeons and five third- and fourth-year orthopedic residents were asked to classify both fracture types on two occasions, with an eight-week interval between the two occasions. RESULTS:The intraobserver agreement for S-H in the expert and resident groups was κ = 0.66 and 0.61, respectively; for Peterson, it was κ = 0.67 and 0.61, respectively. The mean total agreement percentages for S-H and Peterson were 84.5% vs. 83.9%, respectively (t = 0.254; P = 0.8; Cohen's d = 0.20). The overall interobserver agreement for S-H in the first and second observations was κ = 0.57 and 0.63, respectively, and for Peterson, κ = 0.58 and 0.62, respectively. CONCLUSIONS:The S-H and Peterson classifications may have comparable reliability and moderate-to-substantial interobserver agreement, with no significant differences in overall agreement percentages.
INTRODUCTION:This study tests the hypothesis that a novel decontamination-preservation system (DPS) could effectively eradicate relevant pathogens in contaminated, devascularized, extruded osteoarticular fracture fragments while preserving essential viable chondrocyte density (VCD) for joint reconstruction resulting in functional limb preservation. METHODS:With animal care and use committee approval, hounds were anesthetized for captive bolt-induced open bicondylar femoral fractures. One femoral condyle osteoarticular fragment was retrieved and randomly assigned to: Primary Bacterial Contamination (PBC) (n = 3 immediately processed using the DPS) or PBC+Secondary Methicillin-resistantStaphylococcus aureus(MRSA) Contamination (PBC+MRSA) (n = 3 directly inoculated with MRSA, incubated (24 h), then processed using the DPS). The injured limbs were stabilized with external skeletal fixators. One week following fracture, delayed joint reconstruction surgery was performed. Dogs were managed for pain and wound care, and assessed for safety (complete eradication of relevant pathogens) and efficacy (maintenance of VCD to allow for fracture healing and restoration of function, pain relief, and knee range-of-motion (ROM) to >80% of pre-operative levels). RESULTS:All retrieved osteoarticular fragments produced polymicrobial growth with all in the PBC+MRSA cohort including MRSA. The DPS eradicated all relevant pathogens in both cohorts. The induced-fracture was associated with significantly lower VCD (p ≤ .022) when compared to healthy-controls. Mean %Healthy-Control VCD for in situ fragments was 71.6% and for DPS fragments was 65.7% (p = .59). Radiographic fracture healing was documented in all knees by 3 months postoperatively. Function, pain, and ROM were restored to >80% of pre-operative levels. CONCLUSIONRESULTS: provide initial evidence for use of a novel system that combines saline irrigation with 0.002% chlorhexidine immersion followed by shelf-stable point-of-care storage in MOPS® for decontaminating devascularized, contaminated, extruded osteoarticular fracture fragments while maintaining chondrocyte viability. Using this system, contaminated, devascularized, extruded osteoarticular fragments from type 3 open articular fractures were retained, stored for at least 7 days, and used as osteochondral autografts for subsequent joint reconstruction for safe and effective limb preservation in a preclinical canine model.
BACKGROUND:Nonunion and malunion of upper extremity fractures are uncommon but challenging complications, particularly when associated with infection, deformity, or multiple previous operations. Although internal fixation remains the standard treatment, external fixation based on Ilizarov principles offers advantages in complex situations including infection control, deformity correction, and gradual bone reconstruction. This study evaluates the indications, surgical technique, and outcomes of external fixation as a definitive treatment for nonunion and malunion of the upper extremity. METHODS:A retrospective study was conducted including patients treated for nonunion or malunion of humeral and forearm fractures using external fixation as the definitive method of treatment. Hybrid or circular frames were applied according to fracture location. Corticotomy and gradual deformity correction were performed following the principles of Ilizarov and the law of tension-stress. Patients were evaluated clinically and radiographically for union, deformity correction, pain, function, and complications. RESULTS:A total of 45 patients were included, consisting of 7 malunions, 8 aseptic nonunions, and 30 septic nonunions. Patients' ages ranged from 6 to 62 years. The mean time from injury to definitive treatment was 29.7 months. The average external fixation time was 7.9 months and mean follow-up was 38.7 months. Complete radiological union was achieved in all cases. Mechanical alignment was restored in most patients, with minor residual humeral varus (<10°) in five cases. The mean VAS pain score was 2.1 and mean patient satisfaction score was 8.7. Superficial Pin-tract infection occurred in patients but was successfully managed with local care and antibiotics. CONCLUSION:External fixation using Ilizarov principles represents an effective promising and reliable treatment for upper extremity nonunion and malunion. It allows simultaneous infection control, deformity correction, and bone healing without the need for bone grafting, particularly in complex cases with poor bone stock or multiple previous operations.
OBJECTIVE:This study aimed to describe the surgical strategies, the patterns of complications, and their subsequent management in patients with infected Gustilo-Anderson type 3B open tibial fractures. MATERIALS AND METHODS:A retrospective chart review was conducted for the period between January 2010 and January 2024 at a single institution. A total of 27 patients with infected Type 3B tibial fractures were eligible for inclusion in the final analysis. The diagnosis of infection was established by incorporating clinical parameters, including wound and discharge characteristics, odor, microbiological cultures, and inflammatory markers. Demographic and clinical data, including age, gender, mechanism of injury, and total follow-up duration, were recorded. Furthermore, the interval between interventions, the presence and dimensions of bone defects, and the specific fixation methods were analyzed. Time to osseous union was determined based on serial follow-up radiographs. Pathogen identification was performed through a review of culture results, and the specific tissue transfer techniques utilized for soft tissue coverage were documented. Additionally, all observed complications and the frequency and extent of secondary interventions were recorded. RESULTS:Mean age was 34.3 (± 14.6) years. Median follow-up period was 27 (12-140) months. For soft tissue coverage, an anterolateral thigh flap was used in 14 cases (51.9%), local flaps in 4 cases (14.8%), osteocutaneous vascularized fibular grafts in 3 cases (11.1%), lateral arm flap in 2 cases (7.4%), sural artery flap in 2 cases (7.4%), latissimus dorsi flap in 1 case (3.7%), and superficial circumflex iliac artery perforator flap in 1 case (3.7%). A total of 31 complications were identified across the 27 patients. The most frequent complications were flap compromise and secondary infection, each occurring in 8 instances (25.8%), while nonunion was reported in 7 cases (22.5%). The median number of surgical interventions per patient was 7, with a range of 2-15 procedures. CONCLUSION:Infected type 3B tibial open fractures are associated with high rates of complications and secondary interventions. Effective management of such complications is possible with broad range of soft tissue and bone reconstruction techniques.
This study investigates the association of pre-crash factors (i.e., driver/rider behaviors and roadway conditions), and emergency response attributes (pre-hospital time (PHT) and mode of evacuation) with clinical outcomes directly and through the three post-crash clinical indicators, harnessing an extensive hospital-based dataset (N = 273,362) collected in Karachi (Pakistan). The three jointly estimated ordered probit models for post-crash clinical indicators including Glasgow Coma Scale (GCS), Systolic Blood Pressure (SBP), and Respiratory Rate (RR) outperformed their independent counterparts, while a multinomial logit model estimated the association of the three post-crash clinical indicators (along with other explanatory variables) with the final clinical outcomes (e.g., mortality, admitted, discharge etc.) in RTCs. The findings reveal that underage driving/riding significantly increases the chance of severe GCS (3-8), RR (<10 bpm), and SBP (<76 mmHg) by 1.959%, 0.957%, and 0.842%, respectively. Delay in pre-hospital time significantly worsens the three post-crash clinical indicators. On the other hand, the chance of severe GCS, SBP, and RR reduced significantly by 6.657%, 5.728%, and 5.528%, respectively, if a private vehicle was used for evacuation. Based on the clinical outcome model, severe GCS, SBP, and RR (compared to their normal values) increase the chance of mortality by 0.444%, 3.149%, and 6.785%, respectively, underscoring RR as the most critical indicator. The findings of path analysis further highlighted indirect effects surpassing direct ones; for example, pre-crash medical conditions of crash victims (mostly drivers/riders) directly increase the chance of mortality by 0.538%; however, in total (after considering indirect effects) by 1.670% via severe post-crash clinical indicators, where the latter is ∼3 times the direct effects. These outcomes underline the significance of effective and well-timed emergency response. Practical implications are discussed in the paper.
BACKGROUND:Fracture-related infection (FRI) of the calcaneus with associated soft tissue defects after open reduction and internal fixation (ORIF) presents significant therapeutic challenges. This study evaluates the efficacy of two filling techniques-bone cement with local flap transfer (BC+LFT) and free myocutaneous flap (FMF)-in managing these complex cases, with consideration of the FRI classification system. METHODS:A retrospective analysis on patients treated between June 2017 and June 2024 was done. Based on post-debridement defect size, patients were allocated to BC + LFT (defects ≤3 cm) or FMF (defects >3 cm). All cases were classified according to the FRI criteria. Surgical management included radical debridement, dead space obliteration, and soft tissue reconstruction. Outcomes were assessed via AOFAS hindfoot scores, VAS pain scores, complication rates, and radiographic evaluation. RESULTS:A total of 43 patients were included (25 BC+LFT, 18 FMF). The FMF group had longer operative times and greater blood loss (p < 0.05), but no significant differences were observed in debridement frequency, hospitalization, or complication rates. Both groups showed significant improvement in functional and pain scores at final follow-up. Fracture union was achieved in all cases without recurrence of infection. CONCLUSION:Both BC + LFT and FMF are effective for managing calcaneal FRI with soft tissue defects. The choice of technique should be individualized based on defect size and patient factors, with FRI classification providing valuable guidance for clinical decision-making.
Cortical fragments within the intramedullary canal can pose a challenge during intramedullary nail treatment of tibial and femoral shaft fractures. Complications including reamer entrapment, malunion, and inability to pass final implants have all been reported. To limit soft tissue injury and avoid an open approach, laparoscopic instrumentation can be a useful adjunct to manipulate or retrieve cortical fragments at distant sites. Our objective is to outline a method to remove cortical fragments during treatment of tibial and femoral shaft fracture and characterize the standard shaft lengths diameters, tip configurations and jaw opening widths for common laparoscopic instruments.
Heat production during surgical bone drilling is a serious risk factor for osteonecrosis, and cortical bone damage is observed at temperatures exceeding approximately 47°C for 1 min. Traditional stainless steel (SS316L) drills have high thermal conductivity, which can cause rapid heat transfer, whereas zirconia (ZrO2) has lower thermal conductivity and may result in lower thermal injury. This research comparatively studied SS316L and ZrO2 drills under dry-drilling conditions in terms of diameter (2.5, 3.0, 3.5 mm), drill speed (900, 1100, 1300 rpm), and feed rate (30 & 40 mm/min) using standardised bone blocks with thermocouple temperature monitoring. Findings proved that the two dominant factors were drill diameter and spindle speed. In the case of SS316L, a high temperature of 61 °C was observed at 3 mm dia, 1100 rpm, and 40 mm/min, which is above the necrosis temperature, whereas at the same conditions ZrO2 remained at low temperatures below 46 °C. An increase in feed rate (30-40 mm/min) decreased the Tmax of 2.5 mm SS316L drills (48.0 -39.3 °C) and raised it at 3.5 mm (48.5 -53.5 C). In all the parameters, ΔTmax (SS316L - ZrO2) was positive (15 - 23 °C) with increased diameter and with increased speed, which demonstrates the consistent thermal merit of zirconia. In clinical practice, zirconia drills are better in mid-diameter osteotomies and high-speed operations, whereas SS316L drills have to be irrigated or have parameter changes to reduce the chances of thermal risk.
BACKGROUND:Pediatric radial neck fractures, though rare, pose significant management challenges with several treatment options. Open reduction is typically used for more complex cases, where greater fracture severity may contribute to higher complication rates and poorer outcomes. This study aims to evaluate functional outcomes, complications, and risk factors in a large cohort of pediatric patients treated with open reduction, performed after unsuccessful closed reduction. METHODS:A retrospective cohort study was conducted on 53 pediatric patients (mean age 8 years) with radial neck fractures (Judet 4) treated surgically with open reduction, performed after unsuccessful closed reduction, at a single institution between March 2014 and October 2024. Data on surgical delay, complications, and functional outcomes (Oxford Elbow Score) were collected. Statistical analyses included correlation tests, t-tests, and multivariate regression models to assess predictors of outcomes and complications. RESULTS:The mean Oxford Elbow Score was 96, indicating excellent functional outcomes. Complications occurred in 13.5% of patients, including heterotopic ossification (9.6%), posterior interosseous nerve injury (1.9%), and avascular necrosis (1.9%). Surgical delay was significantly longer in patients with complications (p = 0.038). Multivariate analysis revealed that complications were the most significant predictor of poorer functional outcomes (β = -17.12, p < 0.001), while the surgical delay did not significantly impact outcomes or complication rates. CONCLUSION:Open reduction, performed after unsuccessful closed reduction, for pediatric severe radial neck fractures yields excellent functional outcomes with a low complication rate. Complications, such as heterotopic ossifications, are the primary determinant of poor outcomes, whereas surgical delay and age do not significantly affect results. LEVEL OF EVIDENCE:Level III - Retrospective cohort study.
OBJECTIVES:To determine whether self-reported financial stress is associated with levels of capability during recovery from musculoskeletal injury. METHODS:Design: Cross-sectional survey SETTING: Multiple metropolitan musculoskeletal outpatient specialty offices PATIENT SELECTION CRITERIA: Adult outpatients seeking specialty care within 6 months of a musculoskeletal injury (fracture, tendon rupture, sprain, or dislocation). OUTCOME MEASURES AND COMPARISONS:Capability was measured using the PROMIS Physical Function Computer Adaptive Test. Financial stress was measured using the FACIT-COST Version 2 questionnaire. Explanatory variables included levels of distress and unhelpful thoughts regarding sensations, social health, and sociodemographic characteristics. Associations with capability were examined using bivariate analyses and multivariable linear regression. RESULTS:Among 131 participants (56% men, mean age 42 ± 17 years), and an average of 8 ± 6 weeks had elapsed since injury. In multivariable analysis, higher capability was associated with longer time since injury (regression coefficient [RC] = 0.51, p < 0.01) and uninsured status (relative to Medicare coverage; RC = 13, p < 0.01). Lower capability was observed among unemployed participants (RC = -4.6, p = 0.033) and those with lower extremity injuries (RC = -4.5, p < 0.01). Financial stress demonstrated a modest inverse association with capability (RC = -0.20, p = 0.014). Measures of distress and unhelpful thinking were not independently associated with capability. CONCLUSIONS:LEVEL OF EVIDENCE: Level IIIb, Cross Sectional Observational study.
BACKGROUND:Pelvic fractures, although relatively uncommon, are associated with high economic burden, morbidity, and mortality. Mortality is largely driven by severe associated injuries and high-energy mechanisms. While predictors of mortality are well established, their local applicability for the study institution has not been updated using site-specific data since an earlier regional study (2001-2008). As trauma management protocols have evolved, this study utilizes prediction model development and internal validation-adhering to the TRIPOD guidelines-to update the prognostic value of these established predictors within our institutional context by using site-specific data. METHODS:Data from July 2010 - December 2022 were sourced from a Level I adult Major Trauma Centre's registry. The cohort included patients > =15 years old with Injury Severity Score (ISS)> 12 and pelvic fractures. In-hospital mortality was the outcome of interest. Model development utilized backward elimination for predictor selection into a multivariable logistic regression model, with internal validation via bootstrap methods. Model performance was assessed using the Brier scaled score, and discrimination (c-statistic), and calibration (calibration plot). RESULTS:Out of 1564 included patients, 118 were non-survivors (mortality rate 7.5%). The optimism-adjusted prediction model identified ISS≥ 50 (OR 7.4), age≥ 65 (OR 6.1), and severe head injury (OR 3.6) as strong predictors of mortality. Additional predictors with ORs between 2-3 included ISS 25-49, shock on admission, direct transport from the scene of injury, and severe comorbidity. The model demonstrated good to excellent discrimination with an optimism-adjusted c-statistic of 0.88. CONCLUSIONS:This study developed and internally validated a prediction model for in-hospital mortality in major trauma patients with high-energy pelvic fractures using recent, single-center data, identifying key predictors. Notably, the severity of the pelvic fracture itself was not an independent predictor, indicating that pelvic injuries act primarily as markers of overall systemic injury severity. While optimism-adjusted odds from internal validation were attenuated, the findings remain comparable to the broader literature. External validation is recommended to assess the model's transportability and broader applicability.
BACKGROUND:Understanding patient perspectives on the short-term impact of hospital-based violence intervention programs (HVIPs) is crucial to providing patient-centered care. However, HVIP evaluations often fail to integrate patient-reported outcomes (PROs), relying predominately on distal outcomes (e.g., reinjury, fatality) captured by administrative data sources to determine impact. We aimed to examine how observable program implementation metrics may be related to PROs, including satisfaction with and short-term impacts of a pediatric HVIP. METHODS:We conducted a retrospective cohort study of 357 patients (ages 8-18 years) who participated in our HVIP located within an urban pediatric trauma center. We linked HVIP implementation metrics from case management records and PROs to proxy caregiver-reported satisfaction and outcome data from the HVIP-Client Satisfaction Questionnaire (HVIP-CSQ). We summarized patient demographic and injury characteristics, as well as program implementation metrics and HVIP-CSQ responses. We conducted multivariate linear regression analyses to examine associations between implementation metrics and caregiver-reported satisfaction and outcomes. RESULTS:Patients with (n = 199) and without PROs data (n = 158) had similar demographic, clinical, and HVIP implementation characteristics, though those with PROs were more likely to have been retained in HVIP vs. being lost to follow-up (59% vs. 47%, p = 0.039). Overall, caregivers indicated high satisfaction with program services, improved well-being, increased knowledge of community resources, and self-efficacy to apply new skills and tools. Nearly all PROs were positively associated with HVIP retention and need resolution (p < 0.050). CONCLUSIONS:We observed high levels of caregiver-reported satisfaction with program experiences and short-term outcomes following HVIP participation. Families' positive PROs were associated with measurable aspects of HVIP implementation, including retention and need resolution. This work expands our understanding of short-term impacts of HVIPs from the perspectives of patient families and helps to establish key metrics of program implementation that may influence these outcomes.
BACKGROUND:Gunshot-induced open fractures (ballistic OFs) present significant challenges in trauma management due to high risk of infection and lack of standardized antibiotic prophylaxis protocols. This study evaluates the implementation of an institutional antibiotic prophylaxis protocol for ballistic OFs at a Level I trauma center, assessing its impact on infection rates and protocol adherence. METHODS:A retrospective analysis of patient records was conducted, including all cases of ballistic OFs treated between June 7, 2021, and March 31, 2024. Patients were stratified into pre-implementation and post-implementation groups, with the latter further divided into adherent and non-adherent subgroups. Infection rates, time to antibiotic administration, and demographic and clinical variables were analyzed using chi-squared tests and logistic regression. RESULTS:Among 289 patients included, post-implementation protocol adherence was observed in 36% of cases. Infection rates were 7.1% (12/168, 95% CI 4.1-12.1%) before implementation, and 11.6% (14/121, 95% CI 7.0-18.5%) after with no significant difference (Fisher's exact test, p = 0.276). On multivariable analysis, infection was associated with vancomycin use (adjusted OR 5.24, 95% CI 1.95-13.77, p = 0.001), use of irrigation and debridement (adjusted OR 4.60, 95% CI 1.85-12.24, p = 0.001), and use of flap closure or split-thickness skin graft (adjusted OR 4.70, 95% CI 1.29-16.48, p = 0.020). Protocol non-adherence was predominantly attributable to delayed antibiotic initiation and improper metronidazole dosing in the setting of concomitant bowel injury. CONCLUSIONS:The findings suggest that while the introduction of an institutional antibiotic protocol did not significantly alter infection rates, challenges in adherence underscore the need for enhanced implementation strategies. Associations between infection and variables such as irrigation and debridement, flap reconstruction, and vancomycin use likely reflect underlying injury severity and wound contamination. Improved adherence, particularly in cases involving concomitant bowel injuries, may further optimize outcomes and support antibiotic stewardship in trauma care.
INTRODUCTION:Perioperative anaemia and blood transfusion are common complications in elderly patients with intertrochanteric fractures, impacting recovery. This study aimed to evaluate whether a combined approach of early, continuous antifibrinolytic therapy with tranexamic acid (TXA) plus erythropoietin (EPO) and intravenous iron isomaltoside (IM) reduces transfusion requirements compared to TXA alone or standard care. METHODS:This retrospective analysis included 134 patients aged > 70 years with intertrochanteric fractures treated with proximal femoral nail antirotation. Three perioperative blood management protocols were compared: Control group receiving a single 1 g dose of intravenous TXA; TXA group receiving sequential 1 g TXA every 12 h for 48 h; and TXA + EPO/IM group receiving the sequential TXA regimen plus a single 1000 mg dose of IM and daily 40,000 U EPO. The primary outcome was total perioperative transfusion rate. Secondary outcomes included hidden blood loss (HBL), haemoglobin (Hb) levels, and 90-day complications. RESULTS:From post-traumatic day 2 (POD 2) to POD 3, HBL was significantly lower in the TXA and TXA + EPO/IM groups compared to the control group (P < 0.05). On PODs 2 and 3, Hb levels in the TXA + EPO/IM group were significantly higher than in the TXA group (P < 0.05). The total transfusion rate was significantly lower in the TXA + EPO/IM group (14.0%) compared to both the TXA (32.6%) and Control (63.8%) groups (P < 0.05). The incidence of thromboembolic events and other complications was similar across all three groups. CONCLUSION:TXA early and continuous antifibrinolytic therapy combined with EPO/IM rapid iron supplementation and erythropoiesis appears to safely and effectively reduce the perioperative blood transfusion rate and the occurrence of anemia in elderly patients with intertrochanteric fractures without increasing complication risk.
INTRODUCTION:Fractures in older adults are increasingly burdensome on U.S. emergency departments (EDs) and the greater healthcare system. As the older adult population continues to grow, the number, cost, and complexity of fall-related injuries, particularly fractures are rising. This study aimed to identify national trends and factors associated with fracture-related ED visits among older adults. METHODS:We conducted a retrospective analysis using 2013-2022 National Hospital Ambulatory Medical Care Survey-Emergency Department (NHAMCS-ED) data. Adults aged ≥65 with a primary fracture diagnosis were included. Fractures were then categorized by location and mechanism. Demographic and clinical parameters were compared across age groups: 65-74, 75-84, and ≥85 years. Analyses used SPSS Complex Samples v30.0, accounting for survey design, with p < .05 considered significant. RESULTS:An estimated 5.5% or 12.5 million older adult ED visits were fracture-related from 2013 to 2022. Adults aged 65-74 accounted for 39.1% of visits, followed by 75-84 (33.2%) and ≥85 (27.7%). Falls were the most frequent cause of fracture (74.5%), (p = .002). The proportion of femur fractures rose steadily with age, accounting for 10.9% of fractures in adults 65-74, 21.2% in those 75-84%, and 30.1% in those ≥85 years (p < .001). History of osteoporosis was associated with increasing age along with ambulance transport (60.8%) and hospital admission (46.2%)(p < .05). CONCLUSION:Fracture-related ED visits among older adults vary by age in injury patterns, clinical characteristics, and healthcare utilization. These findings suggest a potential benefit of age-specific strategies, including fall prevention and earlier osteoporosis evaluation.
BACKGROUND:Pediatric femoral shaft fractures are common and often require surgical fixation. Postoperative infections remain a serious complication, yet risk factors specific to this population are not well defined. METHODS:We analyzed 14,037 pediatric patients undergoing non-elective femur fracture fixation in the 2019 and 2022 Kids' Inpatient Database (KID). Multivariable logistic regression identified independent predictors of postoperative soft tissue, device-related, and overall infection. Secondary outcomes included length of stay (LOS) and hospital charges. RESULTS:Infections occurred in 0.6% of patients (0.4% soft tissue, 0.3% device-related). Nondisplaced fractures had sharply increased odds of device infection (OR 35.2, 95% CI 4.7-189.7, p < 0.001), while open fractures were protective (OR 0.12, 95% CI 0.01-0.58, p = 0.039). External fixation conferred the highest infection risk versus intramedullary nailing (OR 4.65, 95% CI 2.25-9.13, p < 0.001). Blood transfusion consistently predicted infection across categories (OR 2.6-3.5, all p < 0.01). Soft tissue infection prolonged LOS (20.5 vs 4.2 days, p < 0.001) and raised hospital charges ($421,798 vs $111,845, p < 0.001). CONCLUSION:This study identifies novel and actionable risk factors for postoperative infection following pediatric femur fracture fixation. Recognition of high-risk groups, including those receiving external fixation or transfusion, may guide targeted prevention, perioperative optimization, and surveillance strategies. These findings have important implications for surgical decision-making and healthcare resource utilization in pediatric orthopedic trauma.
BACKGROUND:Surgical teamwork is widely recognized as a cornerstone of patient safety and care quality, yet the realities of operating room (OR) collaboration often differ from the expectations codified in policies, protocols, and training models. This study aimed to explore how surgical teams navigate the realities of intraoperative care during hip fracture fixation, using the human factors work-as-imagined versus work-as-done framework. METHODS:This study was conducted at a teaching hospital and Level 1 trauma centre in Canada and focused on individuals who work in a high-volume orthopaedic trauma OR. An ethnographic approach facilitated a deep exploration of the culture of the OR and a better understanding of surgical team members' lived experiences. Semi-structured interviews were conducted with surgeons, anesthesiologists, nurses, and radiation technologists (RTs). The interview data were analyzed using thematic analysis with primarily inductive coding; this allowed the insights from the experts to be identified organically, using their own words. A work-as-done versus work-as-imagined framework was used to compare and contrast tensions within the data. RESULTS:Our themes highlighted key mismatches in expectations related to teaching, communication, team functioning, patient care, and the role of RTs in the OR. While participants emphasized psychological safety, clear communication, and collaboration as ideals, many described hierarchical barriers, inconsistent team familiarity, and exclusionary cultural norms that undermined these goals. RTs, in particular, experienced dissonance between their technical importance and their social marginalization within the OR team. CONCLUSIONS:Our findings illuminate how informal norms and interpersonal dynamics shape surgical teamwork in ways that are not aligned with team expectations. This study offers a nuanced, ethnographic contribution to the literature on multidisciplinary collaborations and OR team culture, and provides actionable insight for fostering more inclusive, adaptive, and psychologically safe OR cultures. Ultimately, aligning work-as-imagined with work-as-done is critical for improving collaboration and patient care in complex surgical environments.
BACKGROUND:This review addresses whether one-screw or two-screw percutaneous constructs offer superior outcomes for Tile C pelvic fractures. It compares biomechanical stability and clinical outcomes, weighing potential gains in stability against increased surgical complexity and complication risk. METHODS:A systematic search of PubMed, Embase, and Web of Science identified clinical and biomechanical studies on posterior fixation in Tile C fractures. Inclusion criteria required adult traumatic injuries, percutaneous posterior screw fixation, and reported primary outcomes. Two reviewers independently screened and extracted data. RESULTS:Thirty biomechanical, six clinical, and one mixed-design study met inclusion criteria. One third of biomechanical studies favored the use of both a S1 and S2 screw for greater rigidity, while others showed benefit. Clinical studies showed mixed results, with some benefit for radiographic reduction and fixation failure in high-risk patterns but no consistent functional advantage. Significant heterogeneity in methodologies limited direct comparisons. CONCLUSION:Cumulative biomechanical evidence supports two-screw fixation for increased stability in Tile C fractures, especially unstable patterns. Clinical benefits remain uncertain, emphasizing individualized treatment decisions and the need for standardized future research.
INTRODUCTION:The reamer-irrigator-aspirator (RIA) system is used to harvest a large amount of autologous bone graft, most commonly from the femur. One of its major complications is postoperative fracture resulting from decreased bone strength. Although the number of reported cases is limited, it is a serious issue because it involves fracture in originally healthy bone. While several cadaveric studies have examined post-RIA bone strength, no studies have investigated it using finite element analysis (FEA). The aim of this study was to elucidate the effects of RIA on postoperative femoral strength using FEA. METHODS:Quantitative computed tomography (CT)-based FEA was performed using pre- and postoperative CT images from three patients who underwent RIA of the entire femur for autologous bone grafting during nonunion surgery at our institution. Patient 1: a 60-year-old man who underwent reaming with a reamer 4 mm larger than his isthmus diameter. Patient 2: a 71-year-old woman with a wide endosteal diameter, typical of osteoporotic bone. Patient 3: a 64-year-old woman with cortical penetration on the posterior proximal diaphysis and the anterior supracondylar region. Three loading conditions were analyzed for each patient: (a) axial loading, (b) direct force, and (c) rotation. Fracture load was defined as the minimum load at which at least one shell element failed at the complete fracture site. Fracture sites and fracture loads were compared between the pre- and post-RIA models. RESULTS:In Patients 1 and 2, the decrease in femoral strength after RIA was limited, and fracture sites remained unchanged between the pre- and post-RIA models. In contrast, in Patient 3, who had cortical penetrations after RIA, fractures occurred at the penetration sites under rotational loading, with 78% lower fracture load than before RIA. CONCLUSIONS:The postoperative reduction in biomechanical femoral strength under axial loading, direct force, and rotational loading conditions was minimal in cases without cortical penetration. However, in the penetration model after RIA, fractures occurred at the penetration sites under rotational loading with markedly lower torque. These findings may provide insights for postoperative rehabilitation strategies and for evaluating fracture risk, which represents the most severe complication after RIA.
OBJECTIVES To determine if increased preoperative education on how to manage activities of daily living with a lower extremity external fixator would improve overall patient satisfaction. METHODS Design: Prospective cohort, randomized, double-blinded study.Setting: Level I academic trauma center.Patient Selection Criteria: Patients were prospectively identified for enrollment before undergoing external fixation. Adult patients with any lower extremity fracture requiring placement of a knee or ankle external fixator were included. Exclusion criteria consisted of skeletally immature patients, those with a history of external fixation, altered mental status, or placement of multiple external fixators. Patients were randomized via a stratified block method and were blinded as to whether they had received the preoperative educational intervention.Outcome Measures and Comparisons: Patient satisfaction was determined using a validated modified Leeds Satisfaction Questionnaire distributed at two time points: (1) on postoperative day one or two (Survey A) and (2) after external fixation at a follow-up appointment (Survey B). Patient questionnaires were distributed and collected by a research investigator blinded to the participant’s intervention status. RESULTS A total of 89 patients were included in the analysis. Only one survey question demonstrated a statistically significant difference between the control and intervention groups, with the control group reporting a more favorable response. However, the intervention group consistently exhibited higher minimum scores across all question domains in both surveys. Female patients, individuals with a history of smoking or substance use, and those with open fractures reported significantly lower scores across multiple survey items. Hispanic patients reported greater satisfaction across eight questions and three domains in Survey A. CONCLUSIONS Enhanced preoperative education did not lead to a statistically significant improvement in overall patient satisfaction. However, its potential to reduce dissatisfaction and elevate minimum response scores suggests that it may still provide clinically meaningful benefits.
