OTA international : the open access journal of orthopaedic trauma最新文献

The immune system plays an integral role in the regulation of cellular processes responsible for fracture healing. Local and systemic influences on fracture healing correlate in many ways with fracture-related outcomes, including soft tissue healing quality and fracture union rates. Impaired soft tissue healing, restricted perfusion of a fracture site, and infection also in turn affect the immune response to fracture injury. Modern techniques used to investigate the relationship between immune system function and fracture healing include precision medicine, using vast quantities of data to interpret broad patterns of inflammatory response. Early data from the PRECISE trial have demonstrated distinct patterns of inflammatory response in polytrauma patients, which thereby directly and indirectly regulate the fracture healing response. The clearly demonstrated linkage between immune function and fracture healing suggests that modulation of immune function has significant potential as a therapeutic target that can be used to enhance fracture healing.

Orthopaedic surgeons routinely assess the biomechanical environment of a fracture to create a fixation construct that provides the appropriate amount of stability in efforts to optimize fracture healing. Emerging concepts and technologies including reverse dynamization, "smart plates" that measure construct strain, and FractSim software that models fracture strain represent recent developments in optimizing construct biomechanics to accelerate bone healing and minimize construct failure.

Transcutaneous osseointegration for amputees (TOFA) is an evolving technology that has the potential to revolutionize the interface between the amputee and their prosthesis, showing potential at many levels of amputation. While no amputation is without its challenges, TOFA requires a highly specialized prosthesis and a multidisciplinary team that includes specialized surgeons, physical therapists, wound care teams, and social workers who guide the amputee through surgery, postoperative rehabilitation, and the chronic wound care that goes into maintaining the prosthesis. The infrastructure required to facilitate care pathways that lead to reliable, successful outcomes are unique in each health care setting, including those in advanced health care systems such as the United States and Australia. This article details the emerging evidence supporting the use of this prosthetic interface design and many of the challenges that providers face when establishing programs to offer this type of care in the United States.

Introduction: With the rise in antibiotic resistance, new methodologies are needed to combat musculoskeletal infections. Silver is an antimicrobial that can be synthesized in different forms, but its pharmacokinetics are difficult to control. This study details the antibacterial efficacy and cellular cytotoxicity of a formulation consisting of silver carboxylate (AgCar) released through a titanium dioxide/polydimethylsiloxane matrix with a predictable release profile on Pseudomonas aeruginosa, Acinetobacterium baumannii, and human-derived primary osteoblasts.

Methods: Through an Institutional Animal Care and Use Committee and IRB-approved protocol, AgCar was applied to live Yucatan porcine skin and histologically analyzed for skin penetration. Graphite Furnace Atomic Absorption Spectroscopy (GFAAS) was used to measure elution of AgCar. Dose-response curves were generated through optical density to assess potency. Finally, 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay was used to quantify the cellular cytotoxicity of the novel formulation. The results were subject to statistical analysis using analysis of variance and post hoc Tukey tests.

Results: The silver carboxylate coating demonstrated deep penetration into the epithelium at the level of the deep pilosebaceous glands in animal models. GFAAS testing demonstrated the extended elution profile of silver carboxylate over 96 hours, while 100% silver with no titanium dioxide-polydimethylsiloxane matrix fully eluted within 48 hours. 10x silver carboxylate demonstrated superior antimicrobial activity to antibiotics and other silver formulations and showed minimal cytotoxicity compared with other silver formulations.

Discussion/clinical relevance: Current antimicrobial therapies in wound care and surgical antisepsis, such as chlorhexidine gluconate, have pitfalls including poor skin penetration and short duration of efficacy. The broad antimicrobial activity, extended elution, and deep skin penetration of this AgCar formulation show great promise for surgical site infection and wound care treatment. Novel technology to fight the growing threat of microbial resistance should be at the forefront of orthopaedic surgical site infection prevention and treatment.

Distal femur fractures are challenging injuries to manage, and complication rates remain high. This article summarizes the international and basic science perspectives regarding distal femoral fractures that were presented at the 2022 Orthopaedic Trauma Association Annual Meeting. We review a number of critical concepts that can be considered to optimize the treatment of these difficult fractures. These include biomechanical considerations for distal femur fixation constructs, emerging treatments to prevent post-traumatic arthritis, both systemic and local biologic treatments to optimize nonunion management, the relative advantages and disadvantages of plate versus nail versus dual-implant constructs, and finally important factors which determine outcomes. A robust understanding of these principles can significantly improve success rates and minimize complications in the treatment of these challenging injuries.

Geriatric trauma continues to rise, corresponding with the continuing growth of the older population. These fractures continue to expand, demonstrated by the incidence of hip fractures having grown to 1.5 million adults worldwide per year. This patient population and their associated fracture patterns present unique challenges to the surgeon, as well as having a profound economic impact on the health care system. Pharmacologic treatment has focused on prevention, with aging adults having impaired fracture healing in addition to diminished bone mineral density. Intraoperatively, novel ideas to assess fracture reduction to facilitate decreased fracture collapse have recently been explored. Postoperatively, pharmacologic avenues have focused on future fracture prevention, while shared care models between geriatrics and orthopaedics have shown promise regarding decreasing mortality and length of stay. As geriatric trauma continues to grow, it is imperative that we look to optimize all phases of care, from preoperative to postoperative.

Orthopaedic trauma remains a leading cause of patient morbidity, mortality, and global health care burden. Although significant advances have been made in the diagnosis, treatment, and rehabilitation of these injuries, complications such as malunion, nonunion, infection, disuse muscle atrophy and osteopenia, and incomplete return to baseline function still occur. The significant inherent clinical variability in fracture care such as differing patient demographics, injury patterns, and treatment protocols make standardized and replicable study, especially of cellular and molecular based mechanisms, nearly impossible. Hence, the scientists dedicated to improving therapy and treatments for patients with orthopaedic trauma rely on preclinical models. Preclinical models have proven to be invaluable in understanding the timing between implant insertion and bacterial inoculation on the bioburden of infection. Posttraumatic arthritis (PTOA) can take years to develop clinically, but with a porcine pilon fracture model, posttraumatic arthritis can be reliably induced, so different surgical and therapeutic strategies can be tested in prevention. Conversely, the racehorse presents a well-accepted model of naturally occurring PTOA. With preclinical polytrauma models focusing on chest injury, abdominal injury, multiple fractures, and/or head injury, one can study how various injury patterns affect fracture healing can be systemically studied. Finally, these preclinical models serve as a translational bridge to for clinical application in human patients. With selection of the right preclinical model, studies can build a platform to decrease the risk of emerging technologies and provide foundational support for therapeutic clinical trials. In summary, orthopaedic trauma preclinical models allow scientists to simplify a complex clinical challenge, to understand the basic pathways starting with lower vertebrate models. Then, R&D efforts progress to higher vertebrate models to build in more complexity for translation of findings to the clinical practice.

Posterior malleolus fractures (PMFs) (OTA 43B1.1) are frequently seen in combination with fractures of the fibula, medial malleolus, and distal tibia; they can rarely be seen in isolation. PMFs affect the alignment of the ankle mortise and the stability of syndesmosis. Techniques described for fixation of PMFs include open reduction internal fixation through a posterolateral or posteromedial approach or anterior-to-posterior screw fixation. For selected minimally displaced or nondisplaced fractures of the posterior malleolus, we developed a percutaneous technique through the Achilles tendon for the insertion of a posterior-to-anterior cannulated screw. The technique is described, and a clinical series is reviewed.

Objective: To compare the rates of revision surgery for symptomatic neuromas in patients undergoing primary transtibial amputations with and without targeted muscle reinnervation (TMR).

Design: Retrospective cohort study.

Setting: Level I trauma hospital and tertiary military medical center.

Patients/participants: Adult patients undergoing transtibial amputations with and without TMR.

Intervention: Transtibial amputation with targeted muscle reinnervation.

Main outcome measurements: Reoperation for symptomatic neuroma.

Results: During the study period, there were 112 primary transtibial amputations performed, 29 with TMR and 83 without TMR. Over the same period, there were 51 revision transtibial amputations performed, including 23 (21%) in the patients undergoing primary transtibial amputation at the study institution. The most common indications for revision surgery were wound breakdown/dehiscence (42%, n = 25), followed by symptomatic neuroma 18% (n = 9/51) and infection/osteomyelitis (17%, n = 10) as the most common indications. However, of the patients undergoing primary amputation at the study's institution, there was no difference in reoperation rates for neuroma when comparing the TMR group (3.6%, n = 1/28) and no TMR group (4.0%, n = 3/75) (P = 0.97).

Conclusions: Symptomatic neuroma is one of the most common reasons for revision amputation; however, this study was unable to demonstrate a difference in revision surgery rates for neuroma for patients undergoing primary transtibial amputation with or without targeted muscle reinnervation.

Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: The 10th revision of the International Classification of Diseases (ICD-10) coding system may prove useful to orthopaedic trauma researchers to identify and document populations based on comorbidities. However, its use for research first necessitates determination of its reliability. The purpose of this study was to assess the reliability of electronic medical record (EMR) ICD-10 coding of nonorthopaedic diagnoses in orthopaedic trauma patients relative to the gold standard of prospective data collection.

Design: Nonexperimental cross-sectional study.

Setting: Level 1 Trauma Center.

Patients/participants: Two hundred sixty-three orthopaedic trauma patients from 2 prior prospective studies from September 2018 to April 2022.

Intervention: Prospectively collected data were compared with EMR ICD-10 code abstraction for components of the Charlson Comorbidity Index (CCI), obesity, alcohol abuse, and tobacco use (retrospective data).

Main outcome measurements: Percent agreement and Cohen's kappa reliability.

Results: Percent agreement ranged from 86.7% to 96.9% for all CCI diagnoses and was as low as 72.6% for the diagnosis "overweight." Only 2 diagnoses, diabetes without end-organ damage (kappa = 0.794) and AIDS (kappa = 0.798) demonstrated Cohen's kappa values to indicate substantial agreement.

Conclusion: EMR diagnostic coding for medical comorbidities in orthopaedic trauma patients demonstrated variable reliability. Researchers may be able to rely on EMR coding to identify patients with diabetes without complications or AIDS. Chart review may still be necessary to confirm diagnoses. Low prevalence of most comorbidities led to high percentage agreement with low reliability.

Level of evidence: Level 1 diagnostic.