Background: Advancements in surgical wound management have led to improved healing and reduced complications. Incisional negative pressure wound therapy (iNPWT) is a technique that applies sub-atmospheric pressure to closed surgical wounds, enhancing blood flow, minimizing edema, and promoting tissue repair. Initially developed for chronic wounds, its use has expanded across multiple surgical specialties, including orthopaedic trauma surgery, to reduce complications such as dehiscence, infection, and prolonged healing. While traditional wound care relies on standard closure methods with simple dressings, iNPWT offers additional mechanical support and may lower the risk of deep surgical site infections (SSIs). This review examines the current evidence on iNPWT’s role in preventing SSIs following surgery for lower extremity fractures to guide clinical decision-making and improve patient outcomes. Methods: A systematic search through PubMed and MEDLINE utilizing our inclusion and exclusion criteria yielded seven randomized controlled trials and randomized prospective cohort studies that were subsequently analyzed to determine iNPWT effectiveness. Results: Of the seven studies, five showed a decreased SSI rate compared to standard wound dressing, with the other two exhibiting an increased infection rate. Conclusions: This review critically examines existing literature on iNPWT, analyzing level I and II studies on deep SSI rates in traumatic fractures. The evidence remains inconclusive on whether iNPWT offers a significant advantage over standard wound dressings, highlighting the need for further research to clarify its efficacy and clinical application.

BACKGROUND:Orthopaedic trauma patients may experience poor recall regarding their injury and treatment, impairing postoperative outcomes. We sought to evaluate the impact of a standardized postoperative educational protocol on patient recall, adherence to the treatment plan, and satisfaction. METHODS:Two hundred and twenty adult, English-speaking patients with surgically treated lower-extremity fractures were prospectively included. One hundred and ten patients in the educational intervention cohort met with a non-physician study member after surgery but before hospital discharge. They were given a written questionnaire evaluating knowledge of key aspects of their injury and treatment plan. For incorrectly answered questions, the study team member told the patient the correct answer (e.g., "No, you broke your tibia."). Immediately after, the patient was verbally asked the question again (e.g., "Which bone did you break?"), repeating the process until the answer was correct. The 110 patients in the control cohort did not receive this "teach-back" protocol. During their first postoperative appointment, all 220 patients completed a follow-up questionnaire assessing recall, adherence to the treatment plan, and satisfaction. RESULTS:The control cohort correctly answered 64% of recall-oriented questions versus 89% in the intervention cohort (p < 0.001). Eighty-two percent of control patients versus 89% patients in the intervention cohort adhered to postoperative weight-bearing restrictions (p = 0.09). Eighty-four percent of controls adhered to their deep venous thrombosis prophylaxis regimen versus 99% of the intervention cohort (p < 0.001). On a 5-point Likert scale, controls were less satisfied with their overall orthopaedic care compared with patients in the intervention cohort (mean of 4.38 ± 0.84 versus 4.54 ± 0.63 points; p = 0.02), although this difference was less than the minimal clinically relevant difference of 10% that was defined at study onset. On propensity score-weighted multivariable analysis, receipt of the postoperative educational intervention was the only modifiable factor associated with improvement in patient recall (26% improvement [95% confidence interval, 20% to 31%]; p < 0.001). CONCLUSIONS:Some orthopaedic trauma patients' nonadherence to surgeon recommendations and dissatisfaction with care may be mitigated by postoperative education. This standardized postoperative educational protocol improves orthopaedic trauma patients' recall, adherence to their treatment plan, and satisfaction in a manner requiring minimal time. LEVEL OF EVIDENCE:Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Background: Total knee arthroplasty is a widely endorsed surgical intervention, extensively recognized within the orthopedic field for its efficacy in significantly reducing pain and enhancing overall mobility in patients suffering from advanced stages of osteoarthritis. Despite a general consensus on the core procedural steps, the rapid advancements in implant technology and the nuanced techniques in knee reconstruction have inevitably introduced subtle variations in surgical approaches. These variations often emerge due to individual surgeon preferences, their unique expertise, and comfort levels with specific techniques. Anterior knee pain, however, remains a frequent postoperative complication, likely attributed to the extensive and complex innervation of the patella. To address this challenge, some surgeons have adopted patellar denervation, hypothesizing that by reducing nerve signaling from the patellar region, patients may experience a measurable decrease in pain. Methods: A systematic search was performed to include eight recent level I studies to analyze this issue. Results: Of the eight reviews, there were four strong studies that concluded patellar denervation helps decrease anterior knee pain in the acute period, but this may not last long term. The other four papers did not show a difference in anterior knee pain after denervation. Conclusions: This review synthesizes and critically analyzes the current body of literature, aiming to provide clinicians with evidence-based insights into the potential benefits and limitations of incorporating patellar denervation into their surgical especially during the acute post-operative period.

Industry funds nearly two-thirds of US healthcare research, and industry-sponsorship may produce more favorable research results and conclusions. Medical students report feeling inadequately prepared to avoid negative industry influence. Research of educational interventions that educate students on the potential effects of industry influence is lacking, and no interventions have demonstrated long-term benefit. Surveying and assessing student opinions of the relationship between industry and research may help improve future educational interventions. We surveyed preclinical and clinical students at seven US medical schools regarding their attitudes towards industry conflicts of interest (COIs) in medical research. A total of 466 medical students including 232 preclinical and 234 clinical students completed the survey. Of those who had research experience, clinical students were more likely than preclinical students to look for COIs (62.0% v 45.9%, p = .014) and to consider whether author COIs are pertinent to the article (68.1% v 54.1%, p = .023). Many disagreed that they felt adequately educated on the issue of COIs (42.7%), but most agreed that medical school should take a role in guiding student interactions with industry (65.0%). Students responded that all listed financial relationships between industry and investigator, except for providing food and/or beverage, would likely bias the investigator’s research. Many students feel inadequately educated on industry issues in biomedical research, and most believe medical schools should help guide interactions with industry. Our findings support further development of educational interventions that prepare students to navigate the relationship between industry and medical research during and after medical school.

Osteoarthritis (OA) is a debilitating degenerative joint disease that results in chronic pain and inflammation due to progressive mechanical and proteolytic cartilage degradation. Articular chondrocytes, the main cell type present in cartilage, are responsible for the deposition and maintenance of the cartilage extracellular matrix (ECM). However, following damage and inflammation, chondrocytes undergo hypertrophy, apoptosis, and contribute to inflammation and ECM degradation. NF-κB signaling is known to be dysregulated in OA. TRAPPC9, a vesicle trafficking protein, is known to directly activate NF-κB signaling in neuronal and bone cells, however, the biological significance of this protein in chondrocytes has yet to be elucidated. Here, we demonstrate that TRAPPC9 enhances pro-inflammatory gene and protein expression in murine primary articular chondrocytes. Furthermore, we show that TRAPPC9 elicits these responses via phosphorylation of P-100 that activates non-canonical NF-κB signaling. Taken together, these findings suggest TRAPPC9 may be a potential therapeutic target to decrease inflammation and matrix degradation during OA pathology.

Complex lymphatic anomalies (CLAs) are a set of rare diseases with unique osteopathic profiles. Recent efforts have identified how lymphatic-specific somatic activating mutations can induce abnormal lymphatic formations that are capable of invading bone and inducing bone resorption. The abnormal bone resorption in CLA patients has been linked to overactive osteoclasts in areas with lymphatic invasions. Despite these findings, the mechanism associated with progressive bone loss in CLAs remains to be elucidated. In order to determine the role of osteoblasts in CLAs, we sought to assess osteoblast differentiation and bone formation when exposed to the lymphatic endothelial cell secretome. When treated with lymphatic endothelial cell conditioned medium (L-CM), osteoblasts exhibited a significant decrease in proliferation, differentiation, and function. Additionally, L-CM treatment also inhibited bone formation through a neonatal calvaria explant culture. These findings are the first to reveal how osteoblasts may be actively suppressed during bone lymphatic invasion in CLAs.

Introduction: Inability to drive a motor vehicle due to lower extremity injury is a major inconvenience. Timing of safe return to driving has not been much studied. Objective measurements such as time to brake (TTB) have been proposed; however, utility and concordance of functional outcome measurements have not been previously evaluated. The purpose of this project is to measure these parameters and to assess for associations with ability to safely return to driving, improving the ability of clinicians to assess for measurements of driving readiness without specifically measuring TTB. Methods: A prospective, cohort study of 232 patients with complex lower extremity injuries to the pelvis, acetabulum, hip, femur, knee, tibia, ankle, and foot was performed. Time to brake (TTB) was measured once weightbearing was allowed. Function was assessed by the Musculoskeletal Function Assessment (MFA) questionnaire, and pain, mobility, and physical functions, via patient reported outcome measurement information system (PROMIS) surveys. Results: Patients with longer TTB had significantly elevated MFA scores indicating increased musculoskeletal dysfunction post-injury. As the MFA score increased by 1 point, TTB increased by 0.013 s (p<0.001). PROMIS metrics were also significantly associated with patients experiencing more pain and worse mobility as TTB increased. Discussion: Many patients continue to exhibit musculoskeletal dysfunction several months post-treatment for complex lower extremity injuries. Patients with better PROMIS metrics and MFA scores, and shorter TTB are more appropriate to return to driving. Surgeons may be better informed about safe driving ability by considering these measurements.

Acute monocytic leukemia (AML), a subtype of acute myeloid leukemia, is a rare leukemia found in children. It occurs more frequently in adults over the age of 60. Myocarditis represents inflammation of the muscular layer of the heart, the myocardium causing weakening of the muscles that can lead to hemodynamic instability from a reduced ejection fraction. Myocarditis in the pediatric population is most commonly secondary to a viral or infectious etiology. Hemophagocytic lymphohistiocytosis (HLH) is a rare condition of immune dysregulation characterized by severe organ damage induced by an increased inflammatory response and uncontrolled T-cell and macrophage activation. In this case report, we examine a rare presentation of leukemic myocarditis in the presence of HLH, which displays an uncommon cause of an inflammatory state with several complicated concomitant diagnoses. Our patient developed severe multiorgan dysfunction involving liver and kidney failure that required prolonged critical care support, and the patient expired due to his multiorgan failure. We highlight the unusual clinical presentation of myocarditis in the setting of HLH and AML in this complicated pediatric patient and aim to improve outcomes of patients presenting similarly in the future.

Non-ketotic hyperglycemia is an uncommon cause of hemichorea-hemiballismus syndrome that has been associated with high levels of glucose that are not well controlled. Lesions typically occur in the globus pallidus and putamen, which can be identified via computed tomography (CT) or magnetic resonance imaging (MRI). These lesions generally correspond with ballistic and choreiform movements on the contralateral side of the observed imaging findings. Additionally, amelioration of hyperglycemia is the first -line treatment and usually reduces and resolves these hyperkinetic movement symptoms. This case report demonstrates a case of non-ketotic hyperglycemia hemichorea-hemiballismus syndrome in an individual with a history of poorly controlled type 2 diabetes mellitus and a highly elevated hemoglobin A1C (HbA1C), who subsequently improved with insulin therapy.

Drug-induced lupus (DIL) usually presents after starting a medication known to induce DIL. However unusual presentations are rare, as such, our patient presented with initial signs and symptoms of pericarditis. Once treated as such, he progressively declined to symptoms of angioedema and worsening cardiopulmonary status. On first admission, the patient presented with chest pain that was worsened by laying down and improved by sitting up. CT Angiography (CTA) showed mild pericardial effusion, and EKG showed diffuse ST elevation, both suggestive of pericarditis, for which the patient was discharged on colchicine. The patient was readmitted one day later with swelling of the neck and tongue. The patient was re-evaluated, tested for autoantibodies, and found a positive antinuclear antibody (ANA) suggesting a diagnosis of lupus, most likely due to hydralazine.We report a rare presentation of drug-induced lupus initially presenting with pericarditis which evolved into worsening angioedema which has not been reported in the literature thus far. Pericarditis and angioedema may be the initial presentation for a patient with drug-induced lupus. Antinuclear and anti-histone antibodies are highly sensitive and specific respectfully for drug-induced lupus. Early diagnosis and time -appropriate discontinuation of the offending agent for patients can be life-saving.

Resiliency consists of three core components, which include presence of adversity, protective factors to overcome adversity, and positive outcomes or growth. Therefore, resiliency aligns with the trauma recovery process. This paper describes development of the Trauma Resiliency Scale (tRS) to quantify the resiliency of trauma patients upon presentation and during recovery. Scale items were proposed and reviewed by an expert panel. Group construct validity testing was performed using both individual and focus group feedback with item analysis. Reliability was measured with test-retest administered 14 days apart and evaluated with intraclass correlation coefficient. One hundred and twenty-three items were initially proposed. Following item categorizing, a preliminary 17-item questionnaire was created. The questionnaire was administered to 40 individual participants and a trauma survivor focus group to evaluate construct validity. Following group construct testing, an 18-item Trauma Resiliency Scale (tRS-18) was proposed. Twenty-four participants were given the tRS-18 twice, 14 days apart to establish test-retest. Sixteen of the 18 questions had an intraclass correlation >0.7 (0.793-0.949). The remaining two questions underperformed based on the ICC (0.592 and 0.493) and were manually evaluated for inclusion. The final tRS-18 is a brief, self-administered measure of resiliency designed specifically for trauma patients. Sound psychometric properties including face validity, construct validity, and reliability of the instrument have been demonstrated. The tRS-18 may quantify resiliency at any time point with potential to be predictive of progress during recovery. Level of Evidence III, prognostic.

Exposing children to numerous radiographs in order to diagnose various musculoskeletal injuries is not ideal due to the deleterious side effects of ionizing radiation on growth plates. In particular, Little Leaguer’s Shoulder is a common pediatric and adolescent injury that relies mainly on radiographs in order to recognize and treat. Thus, if other imaging modalities without ionizing radiation, such as ultrasound, can be shown to be reliable and accurate in measuring humeral physeal width, it may serve as a better means of identifying these injuries. The purpose of this study was to assess the consistency of two separate physician measures of proximal humeral epiphysis widening in children ages 12-16. Inter-rater and intra-rater reliability of ultrasound measurements of the proximal humeral epiphysis was calculated among twelve patients with open physes. Longitudinal measurements of the epiphyseal plate were obtained in three locations: just distal to the most lateral aspect of the acromion, 2 cm anterior to that line, and 2 cm posterior to that line with the same measurements repeated on the opposite arm. Measurements were then averaged for an overall width. Overall, no statistically significant variation was found when comparing epiphyseal plate width on dominant versus non-dominant arms. Ultrasonographic measurement of proximal humeral epiphyseal width shows narrow variability when used and interpreted by a sports medicine physician.

Transjugular intrahepatic portosystemic shunt (TIPS) procedures are commonly performed in patients with cirrhosis to decrease the pressure in the portal system. An unusual complication of this procedure is endotipsitis, an infection of the shunt/stent with resultant sustained bacteremia caused by vegetation within the TIPS. The most commonly associated pathogens include staphylococci, enterococci, streptococci, and enteric Gram-negative bacilli. We present a patient who developed endotipsitis due to Klebsiella pneumoniae and presented with refractory K. pneumoniae bacteremia. Our patient had a progressively worsening clinical picture and after recognition of endotipsitis was transferred to another facility for liver transplantation and removal of the TIPS. Rapid diagnosis of endotipsitis in the setting of refractory bacteremia is essential to patient survival.

INTRODUCTION:Orthopedic trauma patients may have poor recall of their injuries and treatment. This may lead to poor adherence to instructions. The purposes of this project were to quantify recall about injury and treatment information, and to assess adherence to postoperative instructions and satisfaction with care. METHODS:A prospective cohort of 110 consecutive adult orthopaedic trauma patients treated for acute injury at a Level 1 trauma center were included. All had undergone surgical treatment of fractures of the pelvis or lower extremity. A brief survey to assess patient recall about injury and treatment knowledge, adherence to weightbearing and DVT recommendations and to evaluate patient satisfaction was administered during the first post-hospital clinic visit. RESULTS:Patients correctly answered 64% of recall-oriented questions. 82% and 83% of patients, respectively, reported adherence to their weightbearing restrictions and their DVT prophylaxis regimen, while 66% of patients reported adherence to both. Forty-two percent of non-adherent patients could not remember their weightbearing restrictions, while 78% of non-adherent patients could not remember their DVT prophylaxis regimen. Average patient satisfaction was 4.3 (range 1-5), with 15% of patients indicating neutral sentiment or dissatisfaction with their care. CONCLUSION:Orthopaedic trauma patients have poor recall, which likely reduces postoperative adherence and may impair patient satisfaction. A postoperative educational protocol focused on improving patient recall may be useful. LEVEL OF EVIDENCE:Level 4, prognostic.

Pulmonary pleomorphic carcinoma (PPC) is a subtype of non-small cell lung cancer that is extremely rare and carries a poor prognosis due to its inadequate response to treatment. Patients that present with PPC often exhibit similar symptoms of other malignancies of the lung, making it hard for clinicians to distinguish between each type. However, cytology and gene mutation testing are two approaches that can aid physicians in an accurate and definitive diagnosis. We present a case of an 88-year-old male patient with a diagnosis of pulmonary pleomorphic carcinoma after experiencing recurrent sanguineous pleural effusions. The patient had no smoking history but did have a history of asbestos exposure and pulmonary fibrosis. The patient underwent thoracotomy with pleurodesis and analysis of the surgical pleural biopsy specimen stained positive for markers indicative of PPC. The pathology report was also consistent with the associated cell morphology. Lung cancer is the leading cause of mortality due to cancer in the United States, and exposure to certain substances contributes to the development of these poorly treatable lung malignancies. Smoking and asbestos exposure are well known to act synergistically with each other as risk factors in developing these lung malignancies. In addition to clinical suspicion, screening for these risk factors with laboratory values and imaging is important to diagnose these rare cases of lung malignancies.

A psoas abscess is a rare infection; it is an accumulation of purulent material within the psoas muscle. Common pathogens include Staphylococcus aureus, streptococci, Escherichia coli, and other enteric Gram-negative bacilli and anaerobes. These abscesses are thought to occur by either hematogenous spread, contiguous spread from adjacent organs, trauma, or local inoculation. Pasteurella multocida is a pathogen that usually infects a patient via a bite or scratch from dogs or cats and causes cellulitis at the site of the injury. Pasteurella multocida may also cause infection by the colonization of human respiratory and gastrointestinal (GI) tracts with spontaneous bacteremia seeding remote organs by the bacterial translocation process. Pasteurella multocida is highly susceptible to penicillins, cephalosporins, and other antibiotics. However, psoas abscesses usually require a drainage procedure as well as an extended course of antibiotics. We present a patient presenting with a psoas abscess due to P. multocida, an uncommon presentation of infection by this bacterium.

The current standard of evaluating septic arthritis in the emergency department involves arthrocentesis analysis and culture. Culture results can then help guide pathogen specific treatment. Without prompt treatment of septic arthritis, the joint undergoes irreversible destruction leading to chronic pain and need for surgical replacement. Therefore, we propose an additional method and process of using ultrasound imaging in order to evaluate certain findings that could be used to help diagnose septic arthritis without having to undergo additional procedures. Using the ultrasound prior to doing arthrocentesis can help increase available information that allows the emergency department physician to use their best clinical judgment as to the proceeding treatment or need for additional testing. This improves the quality of care for our patients in a cost effective manner. By outlining the steps involved, including the specific ultrasound technique, further studies can be guided in order to find specific imaging findings using ultrasonography that correlates to septic arthritis.

Objectives: Health literacy is often poor among trauma patients. We introduced an educational mobile application to newly injured patients. We hypothesized that patients who used the app would be more informed about their injury and treatment recommendations, and that app users would demonstrate greater adherence to treatment recommendations.Design: Prospective, cohort study.Setting: Level 1 trauma center.Patients/Participants: Adult patients with acute orthopaedic injury.Intervention: App with educational information about injuries, treatment, and recovery (bit.ly/traumaapp).Main Outcome Measurements: Survey regarding knowledge about injury and treatment and adherence to recommendations.Results: Three hundred thirty-nine patients were enrolled: 187 received information about the app; 105 of them used the app. Another 234 patients had no prior knowledge about the app. App users were more often female (56.2% vs. 37.6%, P = 0.002). App users were more likely to have completed college (34.3% vs. 13.7%, P < 0.0001). Better health literacy was noted among app users in all measurements, including knowledge of fracture location (69% vs. 39%, P < 0.0001), treatment (100% vs. 93%, P = 0.002), weight-bearing status (96% vs. 88%, P = 0.001), estimated healing time (63% vs. 26%, P < 0.0001), and DVT prophylaxis (93% vs. 81%, P = 0.003).Conclusions: Patients who used the app were more likely to have accurate knowledge in all assessed categories, with over 99% reporting adherence to weight-bearing recommendations. It is probable that this level of knowledge and engagement will enhance various outcomes after injury.Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.