Undergoing Fracture Repair Research Articles

Improving Cephalad Lag Screw Placement in the Femoral Head During Cephalomedullary Nailing Using a Novel Augmented Reality System.

To measure the effect of a novel augmented reality software designed to aid in lag screw placement into the femoral head for cephalomedullary nails. Retrospective cohort study. Single Level I trauma center. Between November 2017 and December 2020, 114 consecutive patients with a hip fracture that underwent repair with a cephalomedullary nail by one of 2 orthopaedic trauma surgeons were reviewed. Fracture classifications included OTA/AO 31-A1, 31-A2, 31-A3, and 31-B3. The first 57 patients underwent fracture repair without the software (control) and the subsequent 57 patients underwent repair with use of the augmented reality software (AR). Tip apex distance (TAD) and femoral head zone (AP: superior, center, inferior; Lateral: anterior, center, posterior) were measured using standardized techniques. The mean TAD was lower for the AR versus control cohort (10.7 ± 2.9 mm vs. 15.4 ± 3.8 mm; P < 0.001). TAD <10 mm for AR versus control: 25 (43.9%) versus 3 (5.3%), P < 0.001. TAD <15 mm for AR versus control: 50 (87.7%) versus 44 (77.2%), P < 0.001. On the AP view, center position was achieved in 50.9% versus 7.0% of cases for the AR versus control cohort, respectively. On the lateral view, center position was achieved in 68.4% versus 12.3% of cases for the AR versus control cohort, respectively. This study suggests that use of the novel augmented reality software for assistance in lag screw positioning within the femoral head improves overall TAD and ability to achieve the center-center position. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patient-Specific Orbital Implants Vs. Pre-Formed Implants for Internal Orbital Reconstruction

ABSTRACT Purpose To compare the outcome of orbital blowout fracture repair by means of pre-formed porous-polyethylene titanium implants (PFI) vs patient-specific porous-polyethylene implants (PSI). Methods Retrospective cohort study. Baseline characteristics, ophthalmic examination results, ocular motility, fracture type, the timing of surgery, implant type, and final relative enophthalmos of all patients operated on for blow-out fractures in a single center were collected and analyzed. Results Twenty-seven patients (mean age 39 years, 9 females) were enrolled. Sixteen underwent fracture repair with PFI and 11 with PSI at 11 months (median) post-trauma. Mean follow-up duration was 1.1 years. Both groups showed significant postoperative improvement in primary or vertical gaze diplopia (P = .03, χ2). Relative enophthalmos improved from −3.2 preoperative PFI to −1.7 mm postoperative PFI, and from −3.0 mm preoperative PSI to −1.1 mm postoperative PSI (P= .1). PSI patients had non-significantly less postoperative enophthalmos and globe asymmetry than PFI patients. The outcome was not influenced by previous surgery, age, sex, number of orbital walls involved in the initial trauma, or medial wall involvement (linear regression). Both groups sustained complications unrelated to implant choice. Conclusion Both PSI and PFI yielded good outcomes in this study. PSI may be a good alternative to PFI in primary or secondary orbital blowout fracture repair with less enophthalmos and globe asymmetry, in spite of the possible disadvantages of production time, a relatively larger design, and challenging insertion. Since it is a mirror image of the uninjured orbit, it may be beneficial in extensive fractures.

Trust but Verify: Discordance in Opioid Reporting Between the Electronic Medical Record and a Statewide Database.

The electronic medical record (EMR) is often used as the primary source for patient medication lists and history. We sought to determine the accuracy of the EMR in documenting opioid prescriptions in patients undergoing fracture repair compared to a statewide database. This retrospective study was conducted at an urban level 1 trauma center. Patients > 18 years old were included if they were admitted directly through the emergency room with isolated single orthopedic injuries. Opioid use and prescription data prior to admission and three months following surgery were collected through the EMR and a California statewide database of controlled substance prescriptions. A 2 x 2 McNemar's test was used to identify discordance between the EMR and Controlled Substance Utilization Review and Evaluation System (CURES). A total of 369 patients were included. The EMR reported that 143 patients had an opioid prescription within 30 days prior to admissioncompared to 75 patients reported by CURES (discordance rate [DR]: 34.7%) (p < 0.001). Between postoperative days (POD) 0-30, the EMR reported that 367 patients had an opioid prescriptioncompared to 285 reported by CURES (DR: 22.8%) (p < 0.001). Between POD 30-60, the EMR reported that 142 patients had an opioid prescriptioncompared to 84 reported by CURES (DR: 34.7%) (p < 0.001). Between POD 60-90, the EMR reported that 83 patients had an active opioid prescriptioncompared to 60 patients reported by CURES (DR: 41.0%) (p = 0.10). There is a significant discordance between the databases in documenting opioid use. Physicians should check multiple sources to best assess active opioid prescriptions.

Prescribing Narcotics for Pain: Reconsider the Fifth Vital Sign.

Prescribing Narcotics for Pain: Reconsider the Fifth Vital Sign.

Influence of screw head diameter on ex vivo fixation of equine lateral condylar fractures with 5.5 mm cortical screws.

To determine the influence of screw head diameter on equine condylar fracture fixation with 5.5 mm cortical screws. Ex vivo, biomechanical study, blinded, matched-pair design. Fifteen pairs of equine third metacarpal (MC3) bones. Lateral condylar fractures were simulated by parasagittal osteotomies and repaired pairwise by 2 × 5.5 mm cortical screws of 8 mm (standard) or 10 mm (modified) head diameter. Interfragmentary compression at maximum screw insertion torque was measured. The instrumented specimens were pairwise stratified for biomechanical testing under the following modalities (n=5): (1) screw insertion torque to failure, (2) quasi-static axial load to failure, and (3) cyclic axial load to 2 mm displacement followed by failure. Tests (1) and (2) were analyzed for yield, maximum, and failure torque/angle and load/displacement, respectively. Number of cycles to 2 mm displacement and failure was assessed from test (3). Maximum insertion torque was greater, and failure angle smaller, when constructs repaired with modified screws were tested (8.1 ± 0.5 vs. 7.4 ± 0.5Nm; P=.0047 and 550 ± 104 vs. 1130 ± 230; P=.008). Axial yield (7118 ± 707 vs. 5740 ± 2267 N; P=.043) and failure load (12 347 ± 3359 vs. 8695 ± 2277 N; P=.043) were greater for specimens repaired with modified screws. No difference was detected between constructs in the number of cycles to 2 mm displacement. Condylar MC3 osteotomies repaired with modified 5.5 mm cortical screws sustained greater maximal hand torque insertion, smaller insertion failure angle and 1.4 fold greater quasi-static failure forces than constructs repaired with standard 5.5 mm screws. Use of modified screws with larger heads may improve the fixation of condylar fractures in horses. These results provide evidence to justify clinical evaluation in horses undergoing fracture repair.

Is it a matter of time? The effect of transfer time on femur fracture outcomes

BackgroundTrauma systems in rural areas often require longdistance transfers for definitive care. Delays in care, such as delayed femurfracture repair have been reported to be associated with poorer outcomes, butlittle...

Orbital haematoma after orbital fracture repair using silicone, polytetrafluorethylene, and poly-L-lactic acid/hydroxyapatite implants

The purpose of this paper was to report the incidence of orbital haematoma formation following the repair of orbital fractures with silicone, polytetrafluorethylene (PTFE), and poly-L-lactic acid/hydroxyapatite (PLLA/HA) implants. This retrospective review examined 234 patients (235 sides) who underwent repair of orbital wall fractures over a six-year period. Of these, 36 patients received a silicone sheet; 49 patients received a silicone sheet with superimposed PTFE implant; and 149 patients (150 sides) received PTFE with or without an underlying PLLA/HA implant. Orbital haematomas were documented in 13 out of 36 patients (36.1%) who underwent fracture repair with a silicone sheet; seven out of 49 patients (14.3%) who had a silicone sheet with a superimposed PTFE implant; and three out of 150 sides (2.0%) with PTFE with or without underlying PLLA/HA. The difference in incidence of orbital haematoma formation was significant among the groups (p < 0.001, Pearson’s chi squared test). In the silicone sheet group, haematomas formed within two weeks of surgery in 11 patients (84.6%). In the silicone sheet with superimposed PTFE implant group, five patients (71.4%) developed orbital haematomas no earlier than after two weeks postoperatively. This study showed that the incidence of orbital haematoma formation following orbital fracture repair is different among the implant materials. The use of PTFE and PLLA/HA implants may minimise this complication.

Liberal and Restrictive Blood Transfusion Strategies in Orthopedic Surgery: Risk Factors for Surgical Site Infection

Background: The identification of risk factors for infections in surgical patients with lower-limb fractures and blood transfusions has increased in recent years. Surgical site infections (SSIs) increase hospitalization, care costs, and patient suffering. Correction surgery for lower-limb fractures and blood transfusion is quite common between surgical procedures. The aim of this study was to describe the relationship between blood transfusion and SSI in patients undergoing orthopedic surgery on lower limbs. Methods: We conducted a prospective cohort study to identify risk factors for SSI in blood transfused patients undergoing fracture repair in lower-limb surgeries between February 2017 and May 2019 in 2 reference tertiary-care hospitals in Belo Horizonte, a city of 3 million people in Brazil. Data regarding patient characteristics, surgical procedures, blood transfusions, and surgical infections were collected. Patient characterization was performed by calculating the absolute and relative frequencies of categorical variables and calculating mean, median, minimum, maximum, standard deviation, and coefficient of variation for quantitative variables. The incidence of surgical site infection, the risk of postoperative hospital death, and the total length of hospital stay were calculated by point estimates and 95% confidence intervals identified by statistical tests of bilateral hypotheses, considering the level of significance of 5%. A multivariate analysis (logistic regression) was performed to identify SSI risk factors. Results: Patients who had an indication for blood transfusion (n = 38) but who did not receive blood (n = 4) had significantly lower hemoglobin, comparing discharge with admission, than the group who received blood. Intraoperative transfusion was a risk factor for SSI (OR, 4.7) (Fig. 1). Among the 205 patients with no indication for transfusion, 98 received blood even without the indication: there was no difference in hemoglobin outcome when discharge and admission were compared, and the 98 patients were exposed to unnecessary risk. Regarding restrictive versus liberal transfusion strategies, there were differences in the variables, age (P = .000), duration of surgery (P = .003), number of comorbidities (P = .000), body mass index (BMI) (P = .027), previous hemoglobin (P = .000), and high hemoglobin (P = .000), considering the transfusion practice employed (Fig. 2). Conclusions: The indications for and definition of protocols and careful evaluation of blood transfusion are critical to avoid infectious complications in orthopedic patients with lower-limb fractures.Funding: NoneDisclosures: None

PIT7 DOES INTRAARTICULAR INVOLVEMENT INCREASE THE RISK OF COMPLICATIONS AFTER FRACTURE REPAIR SURGERY?

Fractures that involve joints are believed to increase the surgical complexity compared to those without joint involvement. This study aims to investigate whether joint involvement increases the risk of surgical complications following fracture repair surgery. Through a data partnership with Mercy Technology Services, a retrospective database analysis of Mercy electronic health records was conducted. Adult patients who underwent fracture repair surgery between 2011-2018 Mercy were identified. Postoperative outcomes assessed included: (1) 3-months infection after surgery, (2) all-cause 3-months readmissions, (3) extended LOS (≥ 3days) and (4) 3-months cardiac/renal/respiratory complications. Propensity score matching was used to maximize similarity between patients with and without joint involvement fracture using the following covariates: age, ASA score, BMI, Insurance, Elixhauser comorbidity score (ECS), gender, procedure year, New Injury Severity Score (NISS) and provider volume. The propensity score matching involved nearest neighbor technique with calipers of width equal to 0.2 of the pooled standard deviation of the logit of the propensity score. Matching ratio was 3:1. Before matching, this study included 14,044 fracture repaired patients, of which 766 were with intraarticular fracture. The mean (SD) of age, ASA, NISS, and ECS for non-intraarticular fracture vs intraarticular fracture were 63±21 vs 51±18, 2.6±0.8 vs 2.5±0.8, 8.9±5.5 vs 12.1±8.5, and 2.8±2.5 vs 2.1±2.1, respectively. After matching, the OR time increased by 52 mins on average (158 vs 106) for patients with intraarticular fracture. Intraarticular fracture was associated with longer length of stay (OR 1.62, 95% CI 1.35-1.93), infection (1.28, 95% CI 1.005-1.64), all cause readmission (1.44, 95% CI 1.15-1.80) and respiratory complications (1.42, 95% CI 1.02-1.98). We did not observe significant association between cardiac and renal complications and intraarticular fracture after PS matching. Joint involvement is associated with higher risk of surgical complications after fracture repair.

Effectiveness of Iodophor vs Chlorhexidine Solutions for Surgical Site Infections and Unplanned Reoperations for Patients Who Underwent Fracture Repair

The risk of developing a surgical site infection after extremity fracture repair is nearly 5 times greater than in most elective orthopedic surgical procedures. For all surgical procedures, it is standard practice to prepare the operative site with an antiseptic solution; however, there is limited evidence to guide the choice of solution used for orthopedic fracture repair. To compare the effectiveness of iodophor vs chlorhexidine solutions to reduce surgical site infections and unplanned fracture-related reoperations for patients who underwent fracture repair. The PREP-IT (Program of Randomized Trials to Evaluate Pre-operative Antiseptic Skin Solutions in Orthopaedic Trauma) master protocol will be followed to conduct 2 multicenter pragmatic cluster randomized crossover trials, Aqueous-PREP (Pragmatic Randomized Trial Evaluating Pre-Operative Aqueous Antiseptic Skin Solution in Open Fractures) and PREPARE (Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities). The Aqueous-PREP trial will compare 4% aqueous chlorhexidine vs 10% povidone-iodine for patients with open extremity fractures. The PREPARE trial will compare 2% chlorhexidine in 70% isopropyl alcohol vs 0.7% iodine povacrylex in 74% isopropyl alcohol for patients with open extremity fractures and patients with closed lower extremity or pelvic fractures. Both trials will share key aspects of study design and trial infrastructure. The studies will follow a pragmatic cluster randomized crossover design with alternating treatment periods of approximately 2 months. The primary outcome will be surgical site infection and the secondary outcome will be unplanned fracture-related reoperations within 12 months. The Aqueous-PREP trial will enroll a minimum of 1540 patients with open extremity fractures from at least 12 hospitals; PREPARE will enroll a minimum of 1540 patients with open extremity fractures and 6280 patients with closed lower extremity and pelvic fractures from at least 18 hospitals. The primary analyses will adhere to the intention-to-treat principle and account for potential between-cluster and between-period variability. The patient-centered design, implementation, and dissemination of results are guided by a multidisciplinary team that includes 3 patients and other relevant stakeholders. The PREP-IT master protocol increases efficiency through shared trial infrastructure and study design components. Because prophylactic skin antisepsis is used prior to all surgical procedures and the application, cost, and availability of all study solutions are similar, the results of the PREP-IT trials are poised to inform clinical guidelines and bring about an immediate change in clinical practice. ClinicalTrials.gov Identifiers: NCT03385304 and NCT03523962.

Plasma Concentration of Butorphanol in Northern Royal Albatross Undergoing Fracture Repair

Plasma Concentration of Butorphanol in Northern Royal Albatross Undergoing Fracture Repair

Effect of intrafragmentary bupivacaine (haematoma block) on analgesic requirements in dogs undergoing fracture repair

ObjectiveTo test the efficacy of intraoperative intrafragmentary administration of bupivacaine (haematoma block) in controlling postoperative pain in dogs undergoing osteosynthesis of long-bone isolated diaphyseal fractures. Study designRandomized, ‘blinded’, placebo-controlled, prospective study. AnimalsA total of 23 client-owned dogs with isolated long-bone fractures. MethodsDogs were allocated randomly to two groups: bupivacaine group (B) or placebo group (P). Group B dogs (n = 11) were administered an intraoperative intrafragmentary injection of 0.5% bupivacaine (1.1 mg kg–1) just before fracture fixation, whereas group P dogs (n = 12) were administered normal saline. Postoperative pain evaluations using the University of Melbourne Pain Scale (UMPS) and algometer were performed upon arrival to the recovery room and 1, 2, 4, 6, 8, 20 and 32 hours later. Algometer measurements were performed on: the incision site, a healthy region near the fracture line and the contralateral healthy limb. When the pain score exceeded 14 points in the UMPS, rescue analgesia was administered. The time-standardised area under the curve (AUCst) was used to compare UMPS scores and mechanical pain thresholds between the two groups. ResultsNone of the group B dogs required rescue analgesia, whereas eight of the 12 group P dogs did (p = 0.001). The pain threshold AUCst at the incision line was higher in group B [16.3 (2.9–41.6) N] than in group P [5.6 (2.5–17.4) N] (p = 0.029). The mean UMPS score AUCst was lower in group B (3.7 ± 1.8) than in group P (9.4 ± 4.6) (p = 0.016). In a small number of animals of both groups that were evaluated radiologically, adequate bone healing was noted. Conclusions and clinical relevanceAn intraoperative bupivacaine haematoma block is a simple, quick and effective method that can be used to aid in postoperative pain control in dogs submitted to long-bone osteosynthesis.

An extended transcaruncular approach for naso-orbito-ethmoid and Le Fort II fracture repair.

Recent advancements in computed tomography have enabled the diagnosis of naso-orbito-ethmoid (NOE) fractures to be made in much greater detail. Surgical access to the upper nasofrontal buttress in NOE fractures, however, has remained unchanged over the past decades. All approaches to these fractures using skin incisions have individual drawbacks. The transcaruncular approach is free of the drawbacks of the cutaneous approaches. We further extended the transcaruncular approach for the treatment of NOE and Le Fort II fractures. Eight patients; six with Markowitz's Type I NOE fractures and two with Le Fort II fractures, underwent fracture repair using an extended transcaruncular approach to access the upper nasofrontal buttress. In all but one case, which required an additional small skin incision on the glabella, the fracture on the upper nasofrontal buttress was repaired through an extended transcaruncular approach without making any skin incisions. All showed excellent fracture re-alignment on post-surgical CT. Complications happened in three cases; those in two cases were attributed to the extended transcaruncular approach, whereas those in the other were not. The extended transcaruncular approach is a promising alternative to current conventional approaches for NOE and Le Fort II fractures, achieving accurate repair without the need for skin incision.

Comparative proteomic analysis of hypertrophic chondrocytes in osteoarthritis.

BackgroundOsteoarthritis (OA) is a multi-factorial disease leading progressively to loss of articular cartilage and subsequently to loss of joint function. While hypertrophy of chondrocytes is a physiological process implicated in the longitudinal growth of long bones, hypertrophy-like alterations in chondrocytes play a major role in OA. We performed a quantitative proteomic analysis in osteoarthritic and normal chondrocytes followed by functional analyses to investigate proteome changes and molecular pathways involved in OA pathogenesis.MethodsChondrocytes were isolated from articular cartilage of ten patients with primary OA undergoing knee replacement surgery and six normal donors undergoing fracture repair surgery without history of joint disease and no OA clinical manifestations. We analyzed the proteome of chondrocytes using high resolution mass spectrometry and quantified it by label-free quantification and western blot analysis. We also used WebGestalt, a web-based enrichment tool for the functional annotation and pathway analysis of the differentially synthesized proteins, using the Wikipathways database. ClueGO, a Cytoscape plug-in, is also used to compare groups of proteins and to visualize the functionally organized Gene Ontology (GO) terms and pathways in the form of dynamical network structures.ResultsThe proteomic analysis led to the identification of a total of ~2400 proteins. 269 of them showed differential synthesis levels between the two groups. Using functional annotation, we found that proteins belonging to pathways associated with regulation of the actin cytoskeleton, EGF/EGFR, TGF-β, MAPK signaling, integrin-mediated cell adhesion, and lipid metabolism were significantly enriched in the OA samples (p ≤10−5). We also observed that the proteins GSTP1, PLS3, MYOF, HSD17B12, PRDX2, APCS, PLA2G2A SERPINH1/HSP47 and MVP, show distinct synthesis levels, characteristic for OA or control chondrocytes.ConclusionIn this study we compared the quantitative changes in proteins synthesized in osteoarthritic compared to normal chondrocytes. We identified several pathways and proteins to be associated with OA chondrocytes. This study provides evidence for further testing on the molecular mechanism of the disease and also propose proteins as candidate markers of OA chondrocyte phenotype.Electronic supplementary materialThe online version of this article (doi:10.1186/s12014-015-9085-6) contains supplementary material, which is available to authorized users.

MicroRNA-33a regulates cholesterol synthesis and cholesterol efflux related genes in osteoarthritic chondrocytes

Several studies have shown that osteoarthritis (OA) is strongly associated with metabolism-related disorders, highlighting OA as the fifth component of the metabolic syndrome (MetS). On the basis of our previous findings on dysregulation of cholesterol homeostasis in OA, we were prompted to investigate whether microRNA-33a (miR-33a), one of the master regulators of cholesterol and fatty acid metabolism, plays a key role in OA pathogenesis. Articular cartilage samples were obtained from 14 patients with primary OA undergoing total knee replacement surgery. Normal cartilage was obtained from nine individuals undergoing fracture repair surgery. Bioinformatics analysis was used to identify miR-33a target genes. miR-33a and sterol regulatory element-binding protein 2 (SREBP-2) expression levels were investigated using real-time PCR, and their expression was also assessed after treatment with transforming growth factor-β1 (TGF-β1) in cultured chondrocytes. Akt phosphorylation after treatment with both TGF-β1 and miR-33a inhibitor or TGF-β1 and miR-33a mimic was assessed by Western blot analysis. Furthermore, we evaluated the effect of miR-33a mimic and miR-33a inhibitor on Smad7, a negative regulator of TGF-β signaling, on cholesterol efflux-related genes, ATP-binding cassette transporter A1 (ABCA1), apolipoprotein A1 (ApoA1) and liver X receptors (LXRα and LXRβ), as well as on matrix metalloproteinase-13 (MMP-13), using real-time PCR. We found that the expression of miR-33a and its host gene SREBP-2 was significantly elevated in OA chondrocytes compared with normal chondrocytes. Treatment of cultured chondrocytes with TGF-β1 resulted in increased expression of both miR-33a and SREBP-2, as well as in rapid induction of Akt phosphorylation, whereas TGF-β-induced Akt phosphorylation was enhanced by miR-33a and suppressed by inhibition of miR-33a, as a possible consequence of Smad7 regulation by miR-33a. Moreover, treatment of normal chondrocytes with miR-33a resulted in significantly reduced ABCA1 and ApoA1 mRNA expression levels and significantly elevated MMP-13 expression levels, promoting the OA phenotype, whereas miR-33a’s suppressive effect was reversed using its inhibitor. Our findings suggest, for the first time to our knowledge, that miR-33a regulates cholesterol synthesis through the TGF-β1/Akt/SREBP-2 pathway, as well as cholesterol efflux-related genes ABCA1 and ApoA1, in OA chondrocytes, pointing to its identification as a novel target for ameliorating the OA phenotype.

MicroRNA-33a regulates cholesterol synthesis and cholesterol efflux-related genes in osteoarthritic chondrocytes.

IntroductionSeveral studies have shown that osteoarthritis (OA) is strongly associated with metabolism-related disorders, highlighting OA as the fifth component of the metabolic syndrome (MetS). On the basis of our previous findings on dysregulation of cholesterol homeostasis in OA, we were prompted to investigate whether microRNA-33a (miR-33a), one of the master regulators of cholesterol and fatty acid metabolism, plays a key role in OA pathogenesis.MethodsArticular cartilage samples were obtained from 14 patients with primary OA undergoing total knee replacement surgery. Normal cartilage was obtained from nine individuals undergoing fracture repair surgery. Bioinformatics analysis was used to identify miR-33a target genes. miR-33a and sterol regulatory element-binding protein 2 (SREBP-2) expression levels were investigated using real-time PCR, and their expression was also assessed after treatment with transforming growth factor-β1 (TGF-β1) in cultured chondrocytes. Akt phosphorylation after treatment with both TGF-β1 and miR-33a inhibitor or TGF-β1 and miR-33a mimic was assessed by Western blot analysis. Furthermore, we evaluated the effect of miR-33a mimic and miR-33a inhibitor on Smad7, a negative regulator of TGF-β signaling, on cholesterol efflux-related genes, ATP-binding cassette transporter A1 (ABCA1), apolipoprotein A1 (ApoA1) and liver X receptors (LXRα and LXRβ), as well as on matrix metalloproteinase-13 (MMP-13), using real-time PCR.ResultsWe found that the expression of miR-33a and its host gene SREBP-2 was significantly elevated in OA chondrocytes compared with normal chondrocytes. Treatment of cultured chondrocytes with TGF-β1 resulted in increased expression of both miR-33a and SREBP-2, as well as in rapid induction of Akt phosphorylation, whereas TGF-β-induced Akt phosphorylation was enhanced by miR-33a and suppressed by inhibition of miR-33a, as a possible consequence of Smad7 regulation by miR-33a. Moreover, treatment of normal chondrocytes with miR-33a resulted in significantly reduced ABCA1 and ApoA1 mRNA expression levels and significantly elevated MMP-13 expression levels, promoting the OA phenotype, whereas miR-33a’s suppressive effect was reversed using its inhibitor.ConclusionsOur findings suggest, for the first time to our knowledge, that miR-33a regulates cholesterol synthesis through the TGF-β1/Akt/SREBP-2 pathway, as well as cholesterol efflux-related genes ABCA1 and ApoA1, in OA chondrocytes, pointing to its identification as a novel target for ameliorating the OA phenotype.

Short-term complications in hip fracture surgery using spinal versus general anaesthesia

BackgroundSpinal anaesthesia when compared to general anaesthesia has been shown to decrease postoperative morbidity in orthopaedic surgery. The aim of the present study was to assess the differences in thirty-day morbidity and mortality for patients undergoing hip fracture surgery with spinal versus general anaesthesia. MethodsThe American College of Surgeons National Surgical Quality and Improvement Program (NSQIP) database was used to identify patients who underwent hip fracture surgery with general or spinal anaesthesia between 2010 and 2012 using CPT codes 27245 and 27244. Patient characteristics, complications, and mortality rates were compared. Univariate analysis and multivariate logistic regression were used to identify predictors of thirty-day complications. Stratified propensity scores were employed to adjust for potential selection bias between cohorts. Results6133 patients underwent hip fracture surgery with spinal or general anaesthesia; 4318 (72.6%) patients underwent fracture repair with general anaesthesia and 1815 (27.4%) underwent fracture repair with spinal anaesthesia. The spinal anaesthesia group had a lower unadjusted frequency of blood transfusions (39.34% versus 45.49%; p<0.0001), deep vein thrombosis (0.72% versus 1.64%; p=0.004), urinary tract infection (8.87% versus 5.76%; p<0.0001), and overall complications (45.75% versus 48.97%; p=0.001). The length of surgery was shorter in the spinal anaesthesia group (55.81 versus 65.36min; p<0.0001). After multivariate logistic regression was used to adjust for confounders, general anaesthesia (odds ratio, 1.29; 95% confidence interval, 1.14–1.47; p=0.0002) was significantly associated with increased risk for complication after hip fracture surgery. Age, female sex, body mass index, hypertension, transfusion, emergency procedure, operation time, and ASA score were risk factors for complications after hip fracture repair (all p<0.05). ConclusionsPatients who underwent hip fracture surgery with general anaesthesia had a higher risk of thirty-day complications as compared to patients who underwent hip fracture repair with spinal anaesthesia. Surgeons should consider using spinal anaesthesia for hip fracture surgery.

Direct Posterior Approach for Treatment of Posteromedial Fractures of the Tibial Plateau

Fractures of the tibial plateau that have an associated, displaced posteromedial fracture pattern are difficult to reduce and fix adequately through conventional surgical approaches. The direct posterior approach to posteromedial fractures of the tibial plateau, with the patient in a prone position, has been used to overcome limitations related to conventional posteromedial approaches. The posterior approach allows for fracture reduction by hyperextension of the knee through axial traction over a surgical bump. The technique allows the direct visualization of posteromedial fractures of the tibial plateau without the need for dissection of the neurovascular bundle, and for placement of an antiglide buttress plate at the apex of the posteromedial fracture fragment. Patients undergoing fracture repair through the posterior approach can typically be mobilized on the first day after their surgery with functional rehabilitation and restricted weight bearing for 8 to 10 weeks postoperatively.

Serum Vitamin D Levels in Orthopaedic Trauma Patients Living in the Northwestern United States

To determine the incidence of vitamin D deficiency in orthopaedic trauma patients undergoing fracture surgery living in the Northwest United States. Retrospective observational cohort study. Level 2 trauma center. Two cohorts of patients undergoing fracture repair surgery during a 3-month period in winter and summer had serum vitamin D levels drawn at the time of surgery. One hundred three patients were reviewed in the winter cohort and 98 in the summer cohort. Serum 25(OH) vitamin D levels of patients undergoing fracture repair surgery. Normal levels of vitamin D were considered to be between 32 and 80 ng/mL. Most patients in both cohorts were vitamin D insufficient. The average level for the winter cohort was 26.4 ng/mL, which was significantly lower than the average level for the summer cohort, 29.8 ng/mL (P = 0.03). A high incidence of vitamin D insufficiency and deficiency likely exists across all age groups in orthopaedic trauma patients living in the Northwest United States and regions with similarly northern latitude. Further study is required to confirm improved fracture healing with normalization of serum vitamin D levels. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Oculocardiac reflex in a medial orbital wall fracture without clinically evident entrapment

In this report, we describe a patient with a medial wall orbital fracture, who presented with vasovagal-like symptoms secondary to an oculocardiac reflex. This case is unusual because the patient had no other clinical evidence of muscle entrapment. A 15-year-old male presented with daily 5-10 min episodes of dizziness, light headedness, and nausea consistent with a vasovagal reaction. On examination, the patient had full extra ocular motility and was orthotropic in all fields of gaze. On computed tomography a comminuted medial orbital wall fracture was identified. The adjacent medial rectus muscle was in normal position, but was “rounded” relative to the contralateral side. The patient underwent fracture repair with immediate resolution of all symptoms. Symptoms related to a vasovagal response may occur with orbital fractures despite normal extra ocular motility. Presumably this relates to tension or pulling on an extra ocular muscle, which is not to a degree that alteration in function is appreciable clinically.