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1.  Lessons Learned From Managing a Prospective, Private Practice Joint Replacement Registry: A 25-year Experience 
In 1984, we developed a private practice joint replacement registry (JRR) to prospectively follow patients undergoing THA and TKA to assess clinical and radiographic outcomes, complications, and implant survival. Little has been reported in the literature regarding management of this type of database, and it is unclear whether and how the information can be useful for addressing longer-term questions.
We answered the following questions: (1) What is the rate of followup for THA and TKA in our JRR? (2) What factors affect followup? (3) How successful is this JRR model in capturing data and what areas of improvement are identified? And (4) what costs are associated with maintaining this JRR?
We collected clinical data on all 12,047 patients having primary THA and TKA since 1984. Clinical and radiographic data were collected at routine followup intervals and entered into a prospective database. We searched this database to assess the rate of successful followup and data collection and to compare the effect of patient variables on followup. Costs related to database management were evaluated.
Followup was poor at every time interval after surgery, with a tendency for worsening over time. Patients with a complication and those younger than 70 years tended to followup with greater frequency. There were difficulties with data capture and substantial expenses related to managing the database.
Our findings highlight the difficulties in managing a JRR. Followup is poor and data collection is often incomplete. Newer technologies that allow easier tracking of patients and facilitate data capture may streamline this process and control costs.
Electronic supplementary material
The online version of this article (doi:10.1007/s11999-012-2541-y) contains supplementary material, which is available to authorized users.
PMCID: PMC3549191  PMID: 22948525
2.  Steppingstones to the implementation of an inhospital fracture and dislocation registry using the AO/OTA classification: compliance, completeness and commitment 
Musculoskeletal trauma represents a considerable global health burden, however reliable population-based incidence data are scarce. A fracture and dislocation registry was established within a well-defined population. An audit of the establishment process, feasibility of the registry work and report of the collected data is given.
Demographic data, fracture type and location, mode of treatment, and the reasons for the secondary procedures were collected and scored using recognized systems, such as the AO/OTA classification and the Gustilo-Anderson classification for open fractures. The reporting was done in the operation planning program by the involved orthopaedic surgeon. Both inpatient and day-case procedures were collected. Data were collected prospectively from 2006 until 2010. Compliance among the surgeons and completeness and accuracy of the data was continuously assured by an orthopaedic surgeon.
During the study period, 39 orthopaedic surgeons were involved in the recording of a total of 8,188 procedures, consisting of primary treatment of 4,986 long bone fractures, 467 non long bone fractures, 123 dislocations and 2,612 secondary treatments. In the study period 532 fractures or dislocations were treated at least once for one or more serious complications. For the index year of 2009, a total of 5710 fractures or dislocations were treated in the emergency department or hospitalized, of which the 1594 (28%) were treated at the inpatient or day-case operation rooms, thus registered in the FDR. Quality assurance, educational incentives and continuous feedback between coders and controller in the integrated electronic system are available and used through the features of the electronic database.
Implementing an integrated registry of fractures and dislocations with the electronic hospital system has been possible despite several users involved. The electronic system and the data controller provide for completeness and validity. The FDR has become an indispensable tool for the department for planning and education and will serve as a prerequisite for the conduct and execution of future prospective trials within the department. Further, other departments with similar electronic patient files may fairly easily adopt this system for implementation.
PMCID: PMC2976727  PMID: 20955572
3.  Injuries in Developing Countries—How Can We Help?: The Role of Orthopaedic Surgeons 
Each year nearly 5 million people worldwide die from injuries, approximately the number of deaths caused by HIV/AIDS, malaria, and tuberculosis combined. Ninety percent of these injuries occur in developing countries and that number is growing. Road traffic accidents account for 1.2 million of these 5 million deaths. For each death from trauma, three to eight more are permanently disabled. Orthopaedic surgeons should consider the victims of this epidemic by using their ability and capacity to treat these injuries. SIGN (Surgical Implant Generation Network, Richland, WA, USA) builds local surgical capability in developing countries by providing training and equipment to surgeons for use in treating the poor. It assists in treating long-bone fractures by using an intramedullary nail interlocking screw system. C-arm imaging, unavailable in many of these hospitals, is not necessary to accomplish interlocking. Surgery is performed primarily by local surgeons who record their cases on the SIGN surgical database. Discussion of these reports provides a means of communication and education among surgeons. This database demonstrates the capability of these surgeons. It also demonstrates that the SIGN intramedullary nail is safe for use in the developing world as it has been successful in treating 36,000 trauma patients.
PMCID: PMC2584284  PMID: 18685912
4.  Clinical outcomes of patients with isolated femoral shaft fractures treated with S.I.G.N interlock nails versus Cannulated Interlock Intramedullary nails 
Journal of Orthopaedics  2013;10(4):182-187.
The S.I.G.N (Surgical Implant Generation Network Inc.) solid intramedullary nail is originally designed for tibial shaft fractures and is currently being used for femoral shaft fractures as an extended use. The nail is used in developing nations such as the Philippines, as an alternative for those who could not afford the commercially available nails. The main objective of the study is to determine whether there is a difference in clinical outcomes of patients with isolated femoral shaft fractures in Philippine General Hospital, treated with S.I.G.N intramedullary nails versus Cannulated intramedullary nails, from year 2007 to 2012.
A total of 175 patients fulfilled the inclusion criteria based from reviews of censuses, in-patient and OPD charts of the trauma section of the Department of Orthopedics, Philippine General Hospital. The Surgical Implant Generation Network (S.I.G.N) Fracture Care On-line Database was also screened for patients to be included in the study. A total of 68 patients were able to follow-up, with 48 patients in the S.I.G.N group and 20 patients for the Cannulated group.
Main outcome measures
The dependent variables of the study are radiographic and clinical union, knee range of motion, weight bearing status, and complications.
The subjects were divided into patients operated with S.I.G.N nails and with Cannulated Interlock Intramedullary nails. For the S.I.G.N group, the mean age is 32.1 years and mean follow-up is 40.75 weeks post-op. The Cannulated group has a mean age of 27.9 years and mean follow-up of 35.85 weeks post-op. Radiographic union rate for the S.I.G.N group is 68.8% while for the Cannulated group is 80%. Clinical union and full weight bearing status of patients are 100% in both groups. There is no significant difference with the number of patients with full range of motion in both groups: (S.I.G.N: 85%; Cannulated: 90%). Complication rates are also non-significant (S.I.G.N: 12.5%; Cannulated: 5%).
There is no significant difference between patients with isolated femoral shaft fractures treated with S.I.G.N. Interlock Intramedullary nail versus Cannulated Interlock Intramedullary nail in terms of Clinical and radiographic union, weight bearing, knee range of motion and complication rate.
PMCID: PMC3849246  PMID: 24396239
Femur fractures; SIGN nails; Cannulated nails
5.  Presentation and outcome of traumatic spinal fractures 
Motor vehicle crashes and falls account for most of the spine fractures with subsequent serious disability.
To define the incidence, causes, and outcome of spinal fractures.
Materials and Methods:
Data were collected retrospectively from trauma registry database of all traumatic spinal injuries admitted to the section of trauma surgery in Qatar from November 2007 to December 2009.
Among 3712 patients who were admitted to the section of trauma surgery, 442 (12%) injured patients had spinal fractures with a mean age of 33.2 ± 12 years. The male to female ratio was 11.6:1. Motor vehicle crashes (36.5%) and falls from height (19.3%) were the leading causes of cervical injury (P = 0.001). The injury severity score ranged between 4 and 75. Nineteen percent of cases with cervical injury had thoracic injury as well (P = 0.04). Lumber injury was associated with thoracic injury in 27% of cases (P < 0.001). Combined thoracic and lumber injuries were associated with cervical injury in 33% of cases (P < 0.001). The total percent of injuries associated with neurological deficit was 5.4%. Fifty-three cases were managed surgically for spine fractures; 14 of them had associated neurological deficits. Overall mortalityrate was 5%.
Spine fractures are not uncommon in Qatar. Cervical and thoracic spine injuries carry the highest incidence of associated neurological deficit and injuries at other spinal levels. Young males are the most exposed population that deserves more emphasis on injury prevention programs in the working sites and in enforcement of traffic laws.
PMCID: PMC3519044  PMID: 23248500
Cord injury; fracture; spine; trauma; Qatar
6.  Risk Factors for Infection after 46,113 Intramedullary Nail Operations in Low- and Middle-income Countries 
World Journal of Surgery  2012;37(2):349-355.
The fields of surgery and trauma care have largely been neglected in the global health discussion. As a result the idea that surgery is not safe or cost effective in resource-limited settings has gone unchallenged. The SIGN Online Surgical Database (SOSD) is now one of the largest databases on trauma surgery in low- and middle-income countries (LMIC). We wished to examine infection rates and risk factors for infection after IM nail operations in LMIC using this data.
The SOSD contained 46,722 IM nail surgeries in 58 different LMIC; 46,113 IM nail operations were included for analysis.
The overall follow-up rate was 23.1 %. The overall infection rate was 1.0 %, 0.7 % for humerus, 0.8 % for femur, and 1.5 % for tibia fractures. If only nails with registered follow-up (n = 10,684) were included in analyses, infection rates were 2.9 % for humerus, 3.2 % for femur, and 6.9 % for tibia fractures. Prophylactic antibiotics reduced the risk of infection by 29 %. Operations for non-union had a doubled risk of infection. Risk of infection was reduced with increasing income level of the country.
The overall infection rates were low, and well within acceptable levels, suggesting that it is safe to do IM nailing in low-income countries. The fact that operations for non-union have twice the risk of infection compared to primary fracture surgery further supports the use of IM nailing as the primary treatment for femur fractures in LMIC.
PMCID: PMC3553402  PMID: 23052810
7.  Acute management and outcome of multiple trauma patients with pelvic disruptions 
Critical Care  2012;16(4):R163.
Data on prehospital and trauma-room fluid management of multiple trauma patients with pelvic disruptions are rarely reported. Present trauma algorithms recommend early hemorrhage control and massive fluid resuscitation. By matching the German Pelvic Injury Register (PIR) with the TraumaRegister DGU (TR) for the first time, we attempt to assess the initial fluid management for different Tile/OTA types of pelvic-ring fractures. Special attention was given to the patient's posttraumatic course, particularly intensive care unit (ICU) data and patient outcome.
A specific match code was applied to identify certain patients with pelvic disruptions from both PIR and TR anonymous trauma databases, admitted between 2004 and 2009. From the resulting intersection set, a retrospective analysis was done of prehospital and trauma-room data, length of ICU stay, days of ventilation, incidence of multiple organ dysfunction syndrome (MODS), sepsis, and mortality.
In total, 402 patients were identified. Mean ISS was 25.9 points, and the mean of patients with ISS ≥16 was 85.6%. The fracture distribution was as follows: 19.7% type A, 29.4% type B, 36.6% type C, and 14.3% isolated acetabular and/or sacrum fractures. The type B/C, compared with type A fractures, were related to constantly worse vital signs that necessitated a higher volume of fluid and blood administration in the prehospital and/or the trauma-room setting. This group of B/C fractures were also related to a significantly higher presence of concomitant injuries and related to increased ISS. This was related to increased ventilation and ICU stay, increased rate of MODS, sepsis, and increased rate of mortality, at least for the type C fractures. Approximately 80% of the dead had sustained type B/C fractures.
The present study confirms the actuality of traditional trauma algorithms with initial massive fluid resuscitation in the recent therapy of multiple trauma patients with pelvic disruptions. Low-volume resuscitation seems not yet to be accepted in practice in managing this special patient entity. Mechanically unstable pelvic-ring fractures type B/C (according to the Tile/OTA classification) form a distinct entity that must be considered notably in future trauma algorithms.
PMCID: PMC3580753  PMID: 22913820
8.  Trauma Care in Germany: An Inclusive System 
Development of trauma systems is a demanding process. The United States and Germany both have sophisticated trauma systems. This manuscript is a summary of political, economic, and medical changes that have led to the development of both trauma systems and the current high-quality standards.
We specifically asked three questions: (1) What tasks are involved in developing a modern trauma system? (2) What is the approach to achieve this task? (3) Do these systems work?
We conducted a systematic review of relevant articles by searching electronic databases (PubMed, Embase, Cochrane library) using the following search terms: “trauma system”, “polytrauma”, “trauma networks”, and “trauma registry”. Of 2573 retrieved manuscripts, the authors made a personal selection of studies. A personal study selection from our experiences was added when their contribution to the topic was judged important.
Worldwide, similar tasks concerning trauma care have to be addressed. In most societies, traffic accidents and firearm-related injuries contribute to a high number of trauma victims. The German approach has been to decrease the number of accidents through injury prevention and to provide better care by establishing an emergency medical system. For in-hospital treatment, clinical care has constantly improved and a close interaction with members from the American Association for the Surgery of Trauma and the Orthopaedic Trauma Association has helped a great deal to achieve these improvements. The German healthcare system was developed as a powerful healthcare tool covering patients from injury to rehabilitation. In addition, trauma and injury research has been strengthened to deal with various questions of trauma care.
Organized injury prevention programs and systematized professional patient care can address the issues associated with the global burden of trauma. These trauma systems require constant monitoring and improvement.
PMCID: PMC3734420  PMID: 23633181
9.  Epidemiological Trends of Spine Trauma: An Australian Level 1 Trauma Centre Study 
Global Spine Journal  2013;3(2):75-84.
Knowledge of current epidemiology and spine trauma trends assists in public resource allocation, fine-tuning of primary prevention methods, and benchmarking purposes. Data on all patients with traumatic spine injuries admitted to the Alfred Hospital, Melbourne between May 1, 2009, and January 1, 2011, were collected from the Alfred Trauma Registry, Alfred Health medical database, and Victorian Orthopaedic Trauma Outcomes Registry. Epidemiological trends were analyzed as a general cohort, with comparison cohorts of nonsurvivors versus survivors and elderly versus nonelderly. Linear regression analysis was utilized to demonstrate trends with statistical significance. There were 965 patients with traumatic spine injuries with 2,333 spine trauma levels. The general cohort showed a trimodal age distribution, male-to-female ratio of 2:2, motor vehicle accidents as the primary spine trauma mechanism, 47.7% patients with severe polytrauma as graded using the Injury Severity Score (ISS), 17.3% with traumatic brain injury (TBI), the majority of patients with one spine injury level, 7% neurological deficit rate, 12.8% spine trauma operative rate, and 5.2% mortality rate. Variables with statistical significance trending toward mortality were the elderly, motor vehicle occupants, severe ISS, TBI, C1–2 dissociations, and American Spinal Injury Association (ASIA) A, B, and C neurological grades. Variables with statistical significance trending toward the elderly were females; low falls; one spine injury level; type 2 odontoid fractures; subaxial cervical spine distraction injuries; ASIA A, B, and C neurological grades; and patients without neurological deficits. Of the general cohort, 50.3% of spine trauma survivors were discharged home, and 48.1% were discharged to rehabilitation facilities. This study provides baseline spine trauma epidemiological data. The trimodal age distribution of patients with traumatic spine injuries calls for further studies and intervention targeted toward the 46- to 55-year age group as this group represents the main providers of financial and social security. The study's unique feature of delineating variables with statistical significance trending toward both mortality and the elderly also provides useful data to guide future research studies, benchmarking, public health policy, and efficient resource allocation for the management of spine trauma.
PMCID: PMC3854579  PMID: 24436855
spine trauma; epidemiology; demographics; spinal injury characteristics; neurological status; registry; prevention
10.  Femoral Stress Fractures Associated With Long-term Bisphosphonate Treatment 
Recent studies have described unique clinical and radiographic characteristics of femoral stress fractures or low-energy fractures associated with long-term bisphosphonate therapy. However, it is unclear whether these fractures require subsequent surgery after the initial treatment.
We performed a cohort analysis of bisphosphonate-associated femoral stress fractures to (1) confirm the unique clinical and radiographic findings compared with existing literature, (2) determine whether any patients with completed fractures had no preexisting transverse stress fracture lines, (3) assess the need for additional surgical procedures, and (4) determine whether the hospital length of stay (LOS) differed for patients with prophylactic fixation of stress fractures versus fixation of completed fractures.
We retrospectively reviewed 16 patients with 24 diaphyseal and subtrochanteric femoral stress fractures (14) or low-energy fractures (10) who had been on bisphosphonates for 3 to 10 years. Data included demographics, symptoms, medication history, radiographic characteristics, treatment parameters, LOS, and outcome. Minimum followup was 9 months (average, 44.0 months; median, 31 months; range, 9–112 months).
All patients had clinical and radiographic findings similar to those reported in the literature. Two of four patients sustained completed fractures after radiographs failed to reveal transverse lateral fracture lines. None of the 14 prophylactically treated impending fractures progressed or required additional surgery; however, in five of 10 femurs treated after fracture completion, six additional surgeries were performed. The average hospital LOS was shorter in patients who underwent prophylactic fixation (3.8 days) than in patients treated for completed fractures (5.6 days).
Bisphosphonate-associated stress fractures and completed fractures are unique, possessing subtle characteristic radiographic features. Completed fractures may occur through the thickened bone in the absence of an appreciable transverse stress fracture line. Our observations suggest prophylactic reconstruction nail fixation may avoid fracture completion and may be associated with a shorter hospital LOS and less morbidity than treatment of completed fractures.
Level of Evidence
Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
Electronic supplementary material
The online version of this article (doi:10.1007/s11999-011-2194-2) contains supplementary material, which is available to authorized users.
PMCID: PMC3270181  PMID: 22125247
11.  Electronic Data Capture for Registries and Clinical Trials in Orthopaedic Surgery: Open Source versus Commercial Systems 
Collection and analysis of clinical data can help orthopaedic surgeons to practice evidence based medicine. Spreadsheets and offline relational databases are prevalent, but not flexible, secure, workflow friendly and do not support the generation of standardized and interoperable data. Additionally these data collection applications usually do not follow a structured and planned approach which may result in failure to achieve the intended goal.
Our purposes are (1) to provide a brief overview of EDC systems, their types, and related pros and cons as well as to describe commonly used EDC platforms and their features; and (2) describe simple steps involved in designing a registry/clinical study in DADOS P, an open source EDC system.
Where are we now?
Electronic data capture systems aimed at addressing these issues are widely being adopted at an institutional/national/international level but are lacking at an individual level. A wide array of features, relative pros and cons and different business models cause confusion and indecision among orthopaedic surgeons interested in implementing EDC systems.
Where do we need to go?
To answer clinical questions and actively participate in clinical studies, orthopaedic surgeons should collect data in parallel to their clinical activities. Adopting a simple, user-friendly, and robust EDC system can facilitate the data collection process.
How do we get there?
Conducting a balanced evaluation of available options and comparing them with intended goals and requirements can help orthopaedic surgeons to make an informed choice.
Electronic supplementary material
The online version of this article (doi:10.1007/s11999-010-1469-3) contains supplementary material, which is available to authorized users.
PMCID: PMC3049639  PMID: 20635174
12.  Missed upper cervical spine fracture: clinical and radiological considerations 
This report presents a case of missed upper cervical spine fracture following a motor vehicle accident and illustrates various clinical and radiographic considerations necessary in the evaluation of post traumatic cervical spine injuries. Specific clinical signs and symptoms, as well as radiographic clues should prompt the astute clinician to suspect a fracture even when plain film radiographs have been reported as normal.
Clinical features:
A 44-year-old male was referred for an orthopaedic consultation for assessment of headaches following a high speed head-on motor vehicle accident eleven weeks prior to his presentation. Cervical spine radiographs taken at an emergency ward the day of the collision were reported as essentially normal.
Subsequent radiographs taken eleven weeks later revealed a fracture through the body of axis with anterior displacement of atlas. A review of the initial radiographs clearly demonstrated signs suggesting an upper cervical fracture.
Intervention and outcome:
Initially the patient was prescribed a soft collar which he wore daily until an orthopaedic consultation eleven weeks later. Fifteen weeks following trauma, the patient was considered for surgical intervention, due to persistent headaches associated with the development of neurological signs suggestive of early onset of cervical myelopathy.
Cervical spine fractures can have disastrous consequences if not detected early. A thorough clinical and radiological evaluation is essential in any patient presenting with a history of neck or head trauma. Repeated plain film radiographs are imperative in the event of inadequate visualization of the cervical vertebrae. When in doubt, further imaging studies such as computed tomography or magnetic resonance imaging are required to rule out a fracture.
PMCID: PMC2485171
upper cervical fracture; odontoid fracture; cervical spine trauma; chiropractic
13.  Road Trauma in Teenage Male Youth with Childhood Disruptive Behavior Disorders: A Population Based Analysis 
PLoS Medicine  2010;7(11):e1000369.
Donald Redelmeier and colleagues conducted a population-based case-control study of 16-19-year-old males hospitalized for road trauma or appendicitis and showed that disruptive behavior disorders explained a significant amount of road trauma in this group.
Teenage male drivers contribute to a large number of serious road crashes despite low rates of driving and excellent physical health. We examined the amount of road trauma involving teenage male youth that might be explained by prior disruptive behavior disorders (attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder).
Methods and Findings
We conducted a population-based case-control study of consecutive male youth between age 16 and 19 years hospitalized for road trauma (cases) or appendicitis (controls) in Ontario, Canada over 7 years (April 1, 2002 through March 31, 2009). Using universal health care databases, we identified prior psychiatric diagnoses for each individual during the decade before admission. Overall, a total of 3,421 patients were admitted for road trauma (cases) and 3,812 for appendicitis (controls). A history of disruptive behavior disorders was significantly more frequent among trauma patients than controls (767 of 3,421 versus 664 of 3,812), equal to a one-third increase in the relative risk of road trauma (odds ratio  =  1.37, 95% confidence interval 1.22–1.54, p<0.001). The risk was evident over a range of settings and after adjustment for measured confounders (odds ratio 1.38, 95% confidence interval 1.21–1.56, p<0.001). The risk explained about one-in-20 crashes, was apparent years before the event, extended to those who died, and persisted among those involved as pedestrians.
Disruptive behavior disorders explain a significant amount of road trauma in teenage male youth. Programs addressing such disorders should be considered to prevent injuries.
Please see later in the article for the Editors' Summary
Editors' Summary
In the latest World Health Organization (WHO) global burden of disease list, road traffic crashes are currently ranked eighth but are predicted to take fourth place by 2030 (by which time, road traffic deaths are likely to increase by more than 80% in developing countries and to decrease by nearly 30% in industrialized countries.) Every year, road traffic crashes kill an estimated 1.2 million people world-wide and injure or disable a further 20–60 million. Furthermore, the economic consequences of road traffic crashes account for about 2% of the gross national product of the entire global economy.
90% of road traffic deaths occur in developing countries where pedestrians, cyclists, and users of two-wheel vehicles (scooters, motorbikes) are the most vulnerable. In industrialized countries, teenage male drivers are the single most risky demographic group, with an incidence of road traffic crashes of twice that of the population average. Also, male teenagers are sometimes a hazard to other road users and contribute to more fatalities in older pedestrians than older drivers. Furthermore, teenage male drivers involved in serious crashes can have ongoing health care needs but are often resistant to standard road safety advice.
Why Was This Study Done?
Previous studies have suggested that disruptive behavior disorders might contribute to the risk of road traffic crashes in male teenagers but methodological problems with these studies make these results unclear. Given the importance of this topic, authorities have called for more research into the full range of behavioral disorders and relevant populations. This study attempted to avoid the methodological problems of previous studies and to rigorously assess whether disruptive behavior disorders predispose male teenagers to road traffic crashes.
What Did the Researchers Do and Find?
The researchers conducted a 7-year population-based case-control study in Ontario, Canada of consecutive male teenagers aged between 16 and 19 years who were admitted to a hospital due to a road traffic crash, including those who were pedestrians. For the controls, the researchers used consecutive males in the same age range who were admitted to the same hospitals during the same time interval for acute appendicitis (which is common and generally unrelated to traumatic injury). For each participant in the study, the authors used universal health care databases in Canada's single-payer health care system to identify relevant psychiatric diagnoses (attention deficit hyperactivity disorder, conduct disorder, and oppositional defiant disorder) during the decade before admission.
During the study period, 3,421 male teenagers were admitted to hospital as the result of a road traffic crash and 3,812 male teenagers were admitted to hospital for appendicitis. A history of disruptive behavior disorders was significantly more frequent among male teenagers admitted for road traffic crashes than controls (767 of 3,421 versus 664 of 3,812) giving an odds ratio 1.37. This higher risk was still present after the researchers adjusted for possible confounding factors (such as age, social status, and home location) and accounted for about one-in-20 road traffic crashes, including male teenagers who had died and those involved as pedestrians.
What Do These Findings Mean?
The results of this study suggest that disruptive behavior disorders explain a significant amount of road traffic crashes experienced in male teenagers. Overall, attention deficit hyperactivity disorder, conduct disorder, and oppositional defiant disorder are associated with about a one-third increase in the risk of a road traffic crash (which is similar to the relative risk among individuals treated for epilepsy.) As in previous studies in this area, some methodological problems may affect the interpretation of these findings. As this study did not document who was “at fault,” an alternative interpretation might be that behavioral disorders impair a teenager's ability to avoid a mishap initiated by someone else. Most importantly, the observed increase in risk as pedestrians indicates that male teenagers who abstain from driving do not escape the danger of road traffic crashes.
The researchers stress that any increased risk of road traffic crashes associated with disruptive behavior disorders in male teenagers does not justify withholding a driver's license, especially as many such disorders can be effectively treated or, indeed, because it does not address the issue of the increased risk for those teenagers who were pedestrians. Instead, they suggest that disruptive behavior disorders could be considered as contributors to road traffic crashes—analogous to seizure disorders and some other medical diseases. Therefore, greater attention by primary care physicians, psychiatrists, and community health workers might be helpful since interventions can perhaps reduce the risk including medical treatments and avoidance of distractions.
Additional Information
Please access these Web sites via the online version of this summary at
The World Health Organization has information on road traffic crashes
The US National Institutes of Health has information about behavior disorders in children as well as UK-based Kids Development
The Ontarion Ministry of Transportation has information on annual roadway collisions in Ontario
PMCID: PMC2981585  PMID: 21125017
14.  Long proximal femoral nail in ipsilateral fractures proximal femur and shaft of femur 
Indian Journal of Orthopaedics  2013;47(3):272-277.
Ipsilateral fractures of the proximal femur and femoral shaft are extremely uncommon injuries which occur in young adults who sustain a high energy trauma. A variety of management modalities have been tried to treat this complex fracture pattern ranging from conservative approach to recently introduced reconstruction nails. All these approaches have their own difficulties. We studied the outcome of long proximal femoral nail (LPFN) in the management of concomitant ipsilateral fracture of the proximal femur and femoral shaft.
Materials and Methods:
We analysed the prospective data of 36 consecutive patients who had sustained a high energy trauma (30 closed fractures and 6 open shaft fractures) who had concomitant ipsilateral fractures of the femoral shaft associated with proximal femur fractures treated with LPFN between December 2005 and December 2011. The mean age was 39 years (range 28-64 years). Twenty nine males and seven females were enrolled for this study.
The patients were followed up at three, six, twelve, and eighteen months. The mean healing time for the neck fractures was 4.8 months and for the shaft fractures was 6.2 months. The greater trochanter was splintered and widened in two cases which eventually consolidated. Two patients had superficial infection, two patients had lateral migration of the screws with coxa vara which was due to severe osteoporosis detected during the followup. We had two cases of nonunion of shaft fracture and one case of nonunion of neck fracture. Two cases of avascular necrosis of femoral head were detected after 2 years of followup. No cases of implant failure were noted. Limb shortening of less than 2 cms was noted in four of our patients. The functional assessment system of Friedman and Wyman was used for evaluating the results. In our series 59.9% (n = 23) were rated as good, 30.6% (n = 11) as fair, and 5.5% (n = 2) as poor.
Long PFN is a reliable option for concomitant ipsilateral diaphyseal and proximal femur fractures.
PMCID: PMC3687904  PMID: 23798758
Fracture shaft femur; intracapsular neck fracture; ipsilateral fracture hip and shaft femur; long proximal femoral nail; pertrochanteric fracture
15.  Recurrent Dislocation of the Shoulder Joint 
Dr. Anthony F. DePalma is shown. Photograph provided with kind permission of the Art Committee of Thomas Jefferson University, Philadelphia, PA.
Dr. DePalma was the first editor of Clinical Orthopaedics and Related Research, established by the recently formed Association of Bone and Joint Surgeons. The idea of forming the Association of Bone and Joint surgeons had been conceived by Dr. Earl McBride of Oklahoma City in 1947, and organized by a group of twelve individuals (Drs. Earl McBride, Garrett Pipkin, Duncan McKeever, Judson Wilson, Fritz Teal, Louis Breck, Henry Louis Green, Howard Shorbe, Theodore Vinke, Paul Williams, Eugene Secord, and Frank Hand) [9]. The first organizational meeting was held in conjunction with the 1949 Annual Meeting of the AAOS [9] and the first annual meeting held April 1–2, 1949 in Oklahoma City. Drs. McBride and McKeever invited Dr. DePalma to attend that meeting and join the society. According to DePalma, “Even at this small gathering, there were whisperings of the need of another journal to provide an outlet for the many worthy papers written on clinical and basic science subjects” [7]. The decision to form a new journal was finalized in 1951, and Drs. DePalma and McBride signed a contract with J.B. Lippincott Company. Dr. DePalma was designated Editor-in-Chief, and the journal became a reality in 1953 with the publication of the first volume. From the outset he established the “symposium” as a unique feature, in which part of the articles were devoted to a particular topic. Dr. DePalma served as Editor for 13 years until 1966, when he resigned the position and recommended the appointment of Dr. Marshall R. Urist. At his retirement, Clinical Orthopaedics and Related Research was well established as a major journal.
Dr. Anthony F. DePalma was born in Philadelphia in 1904, the son of immigrants from Alberona in central Foggia, Italy [1]. He attended the University of Maryland for his premedical education, then Jefferson Medical College, from which he graduated in 1929. He then served a two-year internship (common at the time) at Philadelphia General Hospital. Jobs were scarce owing to the Depression, and he felt fortunate to obtain in 1931 a position as assistant surgeon at the Coaldale State Hospital, in Coaldale, Pennsylvania, a mining town. However, he became attracted to orthopaedics and looked for a preceptorship (postgraduate training in specialties was not well developed at this time before the establishments of Boards). In the fall of 1932, he was appointed as a preceptor at the New Jersey Orthopaedic Hospital, an extension of the New York Orthopaedic Hospital. In 1939 he acquired Board certification (the first board examination was offered in 1935 for a fee of $25.00 [2]) and was appointed to the NJOH staff [1].
Dr. DePalma volunteered for military service in 1942, and served first at the Parris Island Naval Hospital in South Carolina, then on the Rixey, a hospital ship. In addition to serving to evacuate casualties to New Zealand, his ship was involved in several of the Pacific island assaults (Guam, Leyte, Okinawa). In 1945, he was assigned to the Naval Hospital in Philadelphia [1].
On his return to Philadelphia, he contacted staff members at Jefferson Medical College, including the Chair, Dr. James Martin, and became good friends with Dr. Bruce Gill (a professor of Orthopaedics at the University of Pennsylvania, and one of the earliest Presidents of the AAOS). After he was discharged from the service, he joined the staff of the Department of Orthopaedic Surgery at Jefferson, where he remained the rest of his career. He succeeded Dr. Martin as Chair in 1950, a position he held until 1970 when he reached the mandatory retirement age of 65. He closed his practice and moved briefly to Pompano Beach, Florida, but the lure of academia proved too powerful, and in January, 1971, he accepted the offer to develop a Division of Orthopaedics at the New Jersey College of Medicine and became their Chair. He committed to a five-year period, and then again moved to Pompano Beach, only to take the Florida State Boards and open a private practice in 1977. His practice grew, and he continued that practice until 1983 at the age of nearly 79. Even then he continued to travel and lecture [1].
We reproduce here four of his many contributions on the shoulder. The first comes from his classic monograph, “Surgery of the Shoulder,” published by J. B. Lippincott in 1950 [2]. In this article he describes the evolutionary development of the shoulder, focusing on the distinction between various primates, and relates the anatomic changes to upright posture and prehensile requirements. The remaining three are journal articles related to frozen shoulder [1], recurrent dislocation [3], and surgical anatomy of the rotator cuff [6], three of the most common shoulder problems then and now. He documented the histologic inflammation and degeneration in various tissues including the coracohumeral ligaments, supraspinatus tendon, bursal wall, subscapularis musculotendinous junction, and biceps tendon. Thus, the problem was rather more global than localized. He emphasized, “Manipulation of frozen shoulders is a dangerous and futile procedure.” For recurrent dislocation he advocated the Magnuson procedure (transfer of the subscapularis tendon to the greater tuberosity) to create a musculotendinous sling. All but two of 23 patients he treated with this approach were satisfied with this relatively simple procedure. (Readers will note the absence of contemporary approaches to ascertain outcomes and satisfaction. The earliest outcome musculoskeletal measures were introduced in the 60s by Larson [11] and then by Harris [10], but these instruments were physician-generated and do not reflect the rather more rigorously validated patient-generated outcome measures we use today. Nonetheless, the approach used by Dr. DePalma reflected the best existing standards of reporting results.) Dr. DePalma’s classic article, “Surgical Anatomy of the Rotator Cuff and the Natural History of Degenerative Periarthritis,” [6] reflected his literature review and dissections of 96 shoulders from 50 individuals “unaware of any (shoulder) disability” and mostly over the age of 40. By the fifth decade, most specimens began to show signs of rotator cuff tearing and he found complete tears in nine specimens from “the late decades.” He concluded,
“Based on the…observations, one can reasonably construct the natural history of periarthritis of the shoulder. It is apparent that aging is an important etiological factor, and with aging certain changes take place in the connective tissue elements of the musculotendinous cuff…it is also apparent that in slowly developing lesions of this nature compensating adjustments in the mechanics of the joint take place so that severe alterations in the mechanics of the joint do not appear. However, one must admit that such a joint is very vulnerable and, if subjected to minor trauma, the existing degenerative lesion would be extended and aggravated.”
Thus, he clearly defined the benign effects of rotator cuff tear in many aging individuals, but also the potential to create substantial pain and disability.
Dr. DePalma was a prolific researcher and writer. In addition to his “Surgery of the Shoulder,” he wrote three other books, “Diseases of the Knee: Management in Medicine and Surgery” (published by J.B. Lippincott in 1954) [4], “The Management of Fractures and Dislocations” (a large and comprehensive two volume work published by W.B. Saunders in 1959, and going through 5 reprintings) [5], and “The Intervertebral Disc” (published by W.B. Saunders in 1970, and written with his colleague, Dr. Richard Rothman) [8]. PubMed lists 62 articles he published from 1948 until 1992.
We wish to pay tribute to Dr. DePalma for his vision in establishing Clinical Orthopaedics and Related Research as a unique journal and for his many contributions to orthopaedic surgery.
DePalma A. Loss of scapulohumeral motion (frozen shoulder). Ann Surg. 1952;135:193–204.DePalma AF. Origin and comparative anatomy of the pectoral limb. In: DePalma AF, ed. Surgery of the Shoulder. Philadelphia: JB Lippincott; 1950:1–14.DePalma AF. Recurrent dislocation of the shoulder joint. Ann Surg. 1950;132:1052–1065.DePalma AF. Diseases of the Knee: Management in Medicine and Surgery. Philadelphia, PA: JB Lippincott Company; 1954.DePalma AF. The Management of Fractures and Dislocations—An Atlas. Philadelphia: WB Saunders Company; 1959.DePalma AF. Surgical anatomy of the rotator cuff and the natural history of degenerative periarthritis. Surg Clin North Am. 1963;43:1507–1520.DePalma AF. A lifetime of devotion to the Janus of orthopedics. Bridging the gap between the clinic and laboratory. Clin Orthop Relat Res. 1991;265:146–169.DePalma AF, Rothman RH. The Intervertebral Disc. Philadelphia: WB Saunders Company; 1970.Derkash RS. History of the Association of Bone and Joint Surgeons. Clin Orthop Relat Res. 1997;337:306–309.Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51:737–755.Larson CB. Rating scale for hip disabilities. Clin Orthop Relat Res. 1963;31:85–93.
PMCID: PMC2505210  PMID: 18264840
16.  Determinants of Mortality in Chest Trauma Patients 
Chest trauma is an important trauma globally accounting for about 10% of trauma admission and 25-50% of trauma death. Different types and severity of chest trauma in different subsets of patients with varying associated injuries result in differing outcomes measured with mortality. Early mitigation of poor prognostic factors could result in improved outcome, therefore the need to know such factors or determinants of mortality in chest trauma patients.
Patients and Methods:
Retrospective and prospective analysis of demographic details, socio-economic, clinical details, modified early warning signs (MEWS) score on presentation, investigation findings, treatment and outcome of chest trauma patients who presented to our cardiothoracic surgery unit was undertaken. Data were collected and were analyzed using WINPEPI Stone Mountain, Georgia: USD Inc; 1995 statistical software.
A total 149 patients with thoracic trauma were studied over a 5 year period constituting 40% of the unit workload. There were 121 males and 28 females (81.2% vs. 18.8%; m: f = 4:1) with age range from 7 to 76 years (mean: 37.42 ± 12.86 years) and about 55% aged 45 years or below and more blunt trauma than penetrating trauma (65.1% vs. 34.9%), but no statistical significance amongst the groups on outcome analysis. Sub-grouping of the 149 patients according to their on-admission MEWS score shows that 141 patients had scores of 9 and less and all survived while the remaining eight had scores >9 but all died. As independent variables, age, sex and type of chest injury did not prove to be correlated with mortality with P values of 0.468, 1.000 and 1.000 respectively. However presence of associated extra thoracic organ injury, high on-admission MEWS score >9, delayed presentation with injury to presentation interval longer than 24 h, and severe chest injury as characterized by bilateral chest involvement correlated positively with mortality with P values of 0.0003, 0.0001, 0.0293 and 0.0236 respectively.
Associated extra thoracic organ injury, high on-admission MEWS score >9, late presentation beyond 24 h post trauma and severe chest injury with bilateral chest involvement were found to be determinants of mortality in chest trauma.
PMCID: PMC3953631  PMID: 24665200
Chest trauma; determinants; mortality
17.  Incidence of Radiographic Cam-Type Impingement in Young Patients (<50) After Femoral Neck Fracture Treated with Reduction and Internal Fixation 
HSS Journal  2013;9(2):113-117.
Cam-type femoral impingement is caused by structural abnormalities of the hip and is recognized as a cause of degenerative hip arthritis. Identifiable etiologies of this structural abnormality include congenital malformation, pediatric hip disease, and malunion of femoral neck fractures after internal fixation.
The purpose of this study was to determine the prevalence of radiographic impingement in healed Orthopaedic Trauma Association (OTA) type 31B fractures treated with reduction and internal fixation.
Seventy OTA 31B hip fractures treated with internal fixation were identified from our institutional trauma database and radiographs were retrospectively reviewed for signs of impingement. Mean follow-up was 53 months after fracture. Alpha angle, Mose templates, and femoral head retroversion were the measurements used to determine impingement.
The overall prevalence of any sign of radiographic impingement was 75%. Alpha angle was elevated in 32 hips (46%), asphericity was present in 46 femoral heads (65%), and femoral head retroversion was present in 26 hips (37%). The rates were highest in displaced subcapital fractures (OTA 31B-3) with a 63% (13/19) prevalence of elevated alpha angle, 68% (14/19) prevalence of asphericity, and 47% (10/19) prevalence of retroversion.
Prevalence of radiographic signs of impingement in this population is higher than expected based on population-based controls. Surgeons must be vigilant about reduction and fixation of femoral neck fractures. Malunion should be recognized as early intervention may be beneficial in improving long-term outcomes.
PMCID: PMC3757494  PMID: 24426855
femoroacetabular impingement; femoral neck fracture; alpha angle; cam lesion
18.  Exercise Protocol for the Treatment of Rotator Cuff Impingement Syndrome 
Journal of Athletic Training  2010;45(5):483-485.
Kuhn JE. Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. J Shoulder Elbow Surg. 2009;18(1):138–160.
Clinical Question:
What is the role of exercise in the treatment of rotator cuff impingement syndrome (RCIS), and what evidence-based exercises can be synthesized into a criterion-standard exercise rehabilitation protocol?
Data Sources:
Investigations were identified by PubMed, Ovid, the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, American College of Physicians Journal Club, and Database of Abstracts of Reviews of Effects. The search terms included shoulder, impingement, rotator cuff, rehabilitation, physical therapy, physiotherapy, and exercise. Additional searches were performed with bibliographies of retrieved studies.
Study Selection:
To qualify for inclusion, studies had to be level 1 or level 2 (randomized controlled trials); had to compare rehabilitation interventions, such as exercise or manual therapy, with other treatments or placebo; had to include validated outcome measures of pain, function, or disability; and had to be limited to individuals with diagnosed impingement syndrome. Impingement syndrome was determined by a positive impingement sign per Neer or Hawkins criteria, or both. Articles were excluded if they addressed other shoulder conditions (eg, calcific tendinosis, full-thickness rotator cuff tears, adhesive capsulitis, osteoarthritis), addressed postoperative management, were retrospective studies or case series, or used other outcome measures.
Data Extraction:
An evidence-based journal club of 9 faculty members and fellows reviewed the articles and extracted and tabulated the data. Individual outcomes for pain, range of motion (ROM), strength, and function were organized. Intragroup and between-groups outcomes were assessed for the effectiveness of treatment, and statistical outcomes were recorded when available. Clinical importance was determined when statistical value was P < .05 and the effect size or difference between treatments was 20% or more. Sixa major categories were created to organize the components of the physical therapy programs used in each study: ROM, flexibility and stretching, strengthening techniques, therapist-driven manual therapy, modalities, and schedule. Components from these categories were used to create a synthesized physical therapy program.
Main Results:
The searches identified 80 studies, of which 11 met the inclusion criteria. In 5 studies, the diagnosis of RCIS was confirmed using an impingement test consisting of lidocaine injected into the subacromial space and elimination of pain with the impingement sign. Randomization methods were used in 6 studies, and blinded, independent examiners were involved in follow-up data collection in only 3 studies. Validated outcome measures were used in all studies. Follow-up was very good in 10 studies and was less than 90% in only 1 study. The specific exercise programs varied among studies. However, general treatment principles were identified among the different studies and included frequency, ROM, stretching or flexibility, strengthening, manual therapy (joint and/or soft tissue mobilizations), modalities, and others.
The findings indicated that exercise improves outcomes of pain, strength, ROM impairments, and function in patients with impingement syndrome. In 10 studies, investigators reported improvements in pain with supervised exercise, home exercise, exercise associated with manual therapy, and exercise after subacromial decompression. Of the 6 studies in which researchers compared pre-exercise pain with postexercise pain, 5 demonstrated that exercise produced statistically significant and clinically important reductions in pain. Two studies demonstrated improvements in pain when comparing exercise and control groups. In 1 study, investigators evaluated bracing without exercise and found no difference in pain between the brace and exercise groups. Investigators evaluated exercise combined with manual therapy in 3 studies and demonstrated improvement in pain relief in each study and improvement in strength in 1 study. In most studies, exercise also was shown to improve function. The improvement in function was statistically significant in 4 studies and clinically meaningful in 2 of these studies. In 2 studies, researchers compared supervised exercise with a home exercise program and found that function improved in both groups but was not different between groups. This finding might have resulted from a type II statistical error. In 4 studies, researchers did not find differences between acromioplasty with exercise and exercise alone for pain alone or for outcomes of pain and function.
Findings indicated that exercise is beneficial for reducing pain and improving function in individuals with RCIS. The effects of exercise might be augmented with implementation of manual therapy. In addition, supervised exercise might not be more effective than a home exercise program. Many articles had methodologic concerns and provided limited descriptions of specific exercises, which made comparing types of exercise among studies difficult. Based on the results, Kuhn generated a physical therapy protocol using evidence-based exercise that could be used by clinicians treating individuals with impingement syndrome. This evidence-based protocol can serve as the criterion standard to reduce variables in future cohort and comparative studies to help find better treatments for patients with this disorder.
PMCID: PMC2938321  PMID: 20831395
function; subacromial impingement; rehabilitation
19.  Preventing and Treating Lower Extremity Stress Reactions and Fractures in Adults 
Journal of Athletic Training  2006;41(4):466-469.
Reference/Citation: Rome K, Handoll HH, Ashford R. Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults. Cochrane Database Syst Rev.20052:CD000450. Update from Gillespie WJ, Grant I. Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults. Cochrane Database Syst Rev.20002: CD000450.
Clinical Question: Do evidence-based interventions exist for the prevention and treatment of stress reactions and stress fractures in young active adults?
Data Sources: This systematic review is an update of the original article, which was published in 2000. The authors conducted a literature review of computerized databases that included the Cochrane Musculoskeletal Injuries Group Specialized Register (April 2004), the Cochrane Central Register of Controlled Trials, MEDLINE (1966 to September 2004), EMBASE (1988 to 2004, week 36), CINAHL (1982 to 2004, September, week 1), Index to Theses (1990 to 2004), and Dissertation Abstracts (1990 to 2004). In addition, the authors searched the Current Controlled Trials at (June 2004, week 1) and the United Kingdom National Research Registrar at (to issue 1, 2004) for current or recently completed studies. They also reviewed the British Journal of Podiatry, International Journal of Podiatric Biomechanics, Physiotherapy, and the Australian Journal of Podiatric Medicine for relevant studies. Furthermore, they contacted the Medical Departments of Defense Forces in Europe and North America to identify unpublished or unlisted military studies. Reference lists of all identified studies and Cochrane reviews were also investigated. The computer search strategy included 61 separate entries and included such terms as stress fractures, stress reactions, shin splints, overuse, athletic injuries, cumulative trauma disorders, running, and randomized controlled trial. The 3 authors of this updated review independently selected new articles for inclusion. Furthermore, the 12 articles that were included in the original systematic review were also reevaluated to ensure they met the defined inclusion criteria.
Study Selection: To qualify for inclusion, studies had to be randomized or quasirandomized control trials, involve interventions to prevent or treat lower extremity stress reactions and fractures, and include physically active adults (adolescence to middle age) who were involved in athletics or military training. Clinical and radiographic (bone scan or x-ray) evidence of a lower extremity stress reaction or stress fracture was also required for inclusion of treatment-based studies. Specifically, skeletal overuse injuries are considered the result of a cumulative and repetitive process that produces initial microstructural changes or stress reactions that are identified by bone scans or magnetic resonance imaging but not conventional radiographs. If cumulative stresses continue, structural changes are visualized on radiographs and are referred to as stress fractures. In addition, research studies involving the treatment of medial tibial stress syndrome or shin splints were excluded. Desired outcome measures for treatment studies included return to training time, return to normal physical activity, functional performance, quality of life measures, resource management (eg, costs, health care visits, diagnostic procedures), adverse effects, and compliance.
The inclusion criteria for stress fracture prevention studies were similar, except that the authors did not have to provide radiographic evidence of a stress fracture or stress reaction. Prevention studies included a combination of the following outcome measures: occurrence and location of stress fracture, stratification of diagnosis, incidence of other lower limb injuries, complications and adverse effects of prevention techniques, resource management, and compliance with the prevention strategy.
Data Extraction: At least 2 reviewers independently extracted the demographic and outcome data from the newly identified studies, and 1 author verified the data and results from the 12 studies included in the 2000 Cochrane review. Inconsistencies from the original review and data from all new studies were also checked by an additional reviewer. All 3 reviewers then independently evaluated the quality of inclusion studies using a quality scoring scheme ( Table). The categories considered included randomization or group allocation (A), intention-to-treat analysis (B), examiner blinding (C), comparison of experimental and control groups at baseline (D), use of a placebo treatment (E), clearly defined subject inclusion and exclusion criteria (F), and methods of outcome assessments (G). Items A through F were scored from 0 to 2 and item G from 0 to 3, for a total “best” quality assessment score (QAS) of 15. Inconsistencies among reviewers' QAS scores were resolved by discussion and with the aid of a discrepancies form.
Main Results: Search criteria identified 24 new studies since the previous review, 8 of which fulfilled the inclusion criteria. In addition, 4 of the 12 studies included in the original 2000 review were excluded. Three were excluded as a result of insufficient indication of subject or group randomization or quasirandomization, and the fourth excluded study included subjects with the diagnosis of medial tibial stress syndrome. Overall, 16 studies were included.
The authors of 13 studies focused on prevention, and 3 groups evaluated the treatment of stress fractures and reactions. The average number of subjects for prevention and treatment studies, respectively, was 1091 (range = 206 to 3025) and 34 (range = 21 to 60). All 13 prevention studies involved military personnel who performed physical training over a 9-to-14–week period. Quality assessment scores for prevention studies ranged from 4 to 10 (mean score = 7). In 9 prevention studies, the effectiveness of insoles or orthoses was evaluated, and the QAS for these studies ranged from 4 to 9 (mean = 6.2). The investigators in 4 studies assessed “shock-absorbing” insoles or orthoses in shoes or boots versus a control (shoes or boots alone), and an additional 5 groups compared insoles and orthoses against one another. One study's authors also evaluated military training in a modified high-top shoe versus standard military boots (QAS = 8). Two groups assessed the influence of pre-exercise stretching (QAS = 8 and 9, respectively), and one investigated the effects of calcium supplementation (QAS = 10).
In none of the prevention studies were adequate randomization and concealment of treatment before group allocation (item A) accomplished, and the researchers in 3 studies randomized groups (team or platoon) instead of individual participants. Attrition rates exceeded 50% in 2 studies, and missing subjects' data were unaccounted for in the final analysis of 3 studies (item B, intention-to-treat analysis). Also, in only 2 of 13 studies were examiners blinded to group assignment (item C). Radiographic (bone scan or x-ray) evidence for diagnostic confirmation of a stress reaction or fracture was used in 12 studies. The method of diagnosis (item G) was based solely on clinical examination or a self-report questionnaire in 2 studies, and diagnostic methods were not described in 2 studies.
Overall fewer osseous stress injuries were reported in the experimental groups for all 4 studies comparing military personnel in “shock absorbing insoles” with controls (no insoles). However, none of these 4 studies demonstrated a statistically significant reduction in lower extremity overuse osseous injuries. In addition, statistically significant results were reported in only 1 of 5 studies that compared various orthoses and insoles. The authors reported a significant reduction in tibial stress fractures for soldiers wearing custom-made semirigid or soft-foot orthoses versus those wearing standard insoles (relative risk = 0.46, 95% confidence interval = 0.22 to 0.93). In a follow-up study, no significant difference in stress fracture rates was seen between subjects who wore custom-made semirigid orthoses and those who wore biomechanical soft orthoses, thus precluding the ability to identify one best design for stress fracture reduction. No significant stress fracture or lower extremity injury rate differences were seen between the control and experimental groups involved in lower extremity stretching studies. Participants taking calcium supplements did not demonstrate a significant reduction in stress fractures (tibial only) versus controls. The differences among the prevention studies prohibited pooling of the data and subsequent meta-analysis. Authors of all 3 treatment studies investigated the effects of a pneumatic ankle foot orthosis (Aircast Corp, Summit, NJ). Follow-up for outcome measures ranged from 78 days to 6 months. Two studies were conducted with military recruits, and the other was conducted with competitive and recreational athletes (n = 18, age range = 18 to 45 years). Treatment QASs ranged from 7/15 to 11/ 15, with an average score of 9.3/15. Proper randomization (item A) and evaluator blinding (item C) were confirmed in 1 of the 3 treatment studies. Data pooled from all 3 studies reached statistical significance for mean number of days until returning to full activities (weighted mean difference with brace versus without brace = −33.39 days, 95% confidence interval = −44.18 to −22.59 days).
Conclusions: Currently, no solid evidence-based interventions to prevent lower extremity stress reactions or fractures exist. Limited evidence suggests that “shock absorbing” insoles may reduce the overall incidence of lower extremity osseous injuries in military personnel. Unfortunately, research does not support the best design for inserts or footwear modifications. There is also insufficient evidence to determine if pre-performance stretching or calcium supplementation offers added protection from lower extremity osseous overuse injuries. Initial evidence supports the use of a pneumatic brace and early mobilization for the treatment of tibal stress reactions and fractures, but additional studies are required to validate these findings. Further investigation concerning the prevention and treatment of lower extremity stress fractures is needed and would assist researchers in establishing and clarifying evidence-based intervention guidelines. Future randomized control trials that clearly define (ie, provide clinical and radiographic evidence for) the diagnosis of a stress fracture or reaction, implement appropriate randomization, and use intervention and outcome measures (functional and performance measurements) that are appropriate for active adults would assist this ongoing and necessary process.
PMCID: PMC1748425  PMID: 17273474
athletic injuries; outcomes assessment
20.  TRAUMA IN TANZANIA: Researching Injury in a low-Resource Setting  
The prevalence of surgical trauma as a global public health hazard has been severely neglected. Trauma surgeons in Uganda and Canada have developed the Kampala Trauma Score (KTS), a trauma severity index specific to east African contexts. Hospitals in Tanzania have begun to use this tool to measure their own trauma management protocols in order to measure the validity of this index regionally. This study sought to enhance analysis of data collected through the KTS, by highlighting the efficacy and the lacunae of this registry through evaluation of the data quality of one ongoing round of data collection at an orthopaedic emergency room in Dar es Salaam, Tanzania. The data was screened for missing values that would have impact on prediction of clinical evolution and also analysed for contradictory evidence. Interviews were conducted with data collectors on the main challenges involved in data gathering and analysis for this project. Analysis of the initial round of data collection confirms road accidents cause the most trauma in Dar es Salaam, with pedestrians being particularly vulnerable. However, critical sources of information such as serious injury scores and two-week followup were inconsistently recorded, thereby limiting outcome measurement. The lack of research resources, both financial and human, had a major impact on the ability to sustain the data collection. While the results of this study demonstrate the public health value of having a mechanism to record trauma, research capacity must be supported in low-resource settings in order to enhance clinical care to accident and injury patients.
PMCID: PMC2997249  PMID: 21152331
Surgery; trauma; global health; data quality; research capacity
21.  Retrograde Versus Antegrade Intramedullary Nailing of Gunshot Diaphyseal Femur Fractures 
The use of retrograde nailing for gunshot wound femur fractures is controversial due to concerns of knee sepsis after this procedure since the knee is entered to introduce the nail into the canal.
We compared retrograde and antegrade nailing for gunshot femur fractures to determine whether (1) knee sepsis or other adverse events were more likely to complicate procedures using retrograde nails, (2) there were differences in surgical time or blood loss, and (3) there were differences in radiographic union.
We retrospectively reviewed our prospective trauma database from 1999 to 2012 for patients with a diagnosis of gunshot and femur fracture. We performed a detailed review of medical records and radiographs for those patients with OTA Classification Type 32 femur fractures secondary to gunshot injury treated with either retrograde or antegrade femoral nailing. Eighty-one patients were treated with intramedullary nailing (53 retrograde and 28 antegrade). We reviewed elements of the operative treatment (procedure, anesthesia time, operative time, and estimated blood loss) for all 81 patients. For clinical and radiographic review, followup was adequate for 43 and 25 patients with retrograde and antegrade nailing, respectively. Minimum followup was 3 months for both groups (retrograde: mean, 41 months; range, 3–148 months; antegrade: 26 months: range, 3–112 months).
No patients in either group developed knee sepsis. No significant differences were found between groups with regard to operative time, blood loss, or radiographic union.
With the numbers available, immediate retrograde nailing appears as safe and effective as antegrade nailing for gunshot femur fractures. Immediate retrograde nailing is as safe as antegrade nailing for gunshot femur fractures.
Level of Evidence
Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
PMCID: PMC3825896  PMID: 23690149
22.  Acute Infections After Fracture Repair 
Managing infections in fractures treated with open reduction and internal fixation is an ongoing dilemma. Little published data exist to support the current practice of treating these infections with retained hardware, irrigation, débridement, and antibiotic suppression. We evaluated the effectiveness of this approach. We identified potential subjects from a central trauma database and selected them based on chart review and specific inclusion and exclusion criteria. We divided the patients into two groups. Patients achieving successful union with original hardware in place were considered as having successful results and patients who required hardware removal before healing were considered to have failed results. Data, including age, gender, tobacco use, diabetic status, site of fracture, Orthopaedic Trauma Association class, open grade, type of fixation, joint involvement, and organism, were gathered and compared between the groups by analysis of variance. Sixty-nine cases were available for analysis. Forty-seven (68%) were successful and 22 (32%) were unsuccessful. Average time to healing was 130 days. Most of the failures occurred within 120 days from the time of injury. Smoking was a major risk factor with a 3.7 times greater likelihood of procedures being unsuccessful per month than procedures among nonsmokers. Treating infected fractures with hardware in place is less successful than widely believed.
Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC2505119  PMID: 18196433
23.  Surgical Dislocation Technique for the Treatment of Acetabular Fractures 
Surgical hip dislocation allows for a 360° view of the acetabulum and may facilitate a reduction in selected acetabular fractures. To our knowledge there is no description in the literature of the different techniques used to reduce acetabular fractures through this approach. The aims of this study are to describe a technique of hip surgical dislocation to treat a variety of acetabular fracture patterns and to ascertain the early results with this technique, including the quality of fracture reductions achieved, clinical results, operative time, and complications such as avascular necrosis and heterotopic ossification.
Description of Technique
The procedure involves digastric trochanteric flip osteotomy and safe dislocation of the femoral head, preserving its vessels. T-type, transverse fractures alone or associated with posterior wall could be reduced with specific clamps and reduction adequacy can be judged by direct view. Anterior column fixation could be performed with one or two screws; the posterior column could be fixed with a single posterior plate or with two plates if a transverse fracture is associated with a posterior wall fracture.
Between 2005 and 2011, we used this approach selectively to manage those types of fractures; during the period in question, we treated 312 acetabular fractures surgically, of which 31 (10%) were treated using this approach. Patient demographic, injury, and surgical variables as well as complications were recorded. Outcomes were evaluated with the Merle d’Aubigné and Postel system. Radiographic outcome was scored according to Matta’s criteria on postoperative radiographs (AP and Judet views). Minimum followup was 24 months (mean, 43 months; range, 24–87 months).
Fracture reduction was defined as anatomic in 65% cases, imperfect in 16%, and poor in 19%. Mean Merle d’Aubigné score was 15 points (out of 18, with higher scores being better). Two patients developed symptomatic femoral head avascular necrosis.
In complex cases, surgical dislocation presents several advantages; a single approach may reduce surgical time, permit direct intraarticular assessment, and facilitate screw placement closer to the articular surface. It also presents several limitations; some difficulties with bone-reduction clamp positioning, limited fixation of the anterior column, and a small risk of greater trochanter malunion.
Electronic supplementary material
The online version of this article (doi:10.1007/s11999-013-3228-8) contains supplementary material, which is available to authorized users.
PMCID: PMC3825905  PMID: 24002867
24.  Infirmity and Injury Complexity are Risk Factors for Surgical-site Infection after Operative Fracture Care 
Orthopaedic surgical-site infections prolong hospital stays, double rehospitalization rates, and increase healthcare costs. Additionally, patients with orthopaedic surgical-site infections (SSI) have substantially greater physical limitations and reductions in their health-related quality of life. However, the risk factors for SSI after operative fracture care are unclear.
We determined the incidence and quantified modifiable and nonmodifiable risk factors for SSIs in patients with orthopaedic trauma undergoing surgery.
Patients and Methods
We retrospectively indentified, from our prospective trauma database and billing records, 1611 patients who underwent 1783 trauma-related procedures between 2006 and 2008. Medical records were reviewed and demographics, surgery-specific data, and whether the patients had an SSI were recorded. We determined which if any variables predicted SSI.
Six factors independently predicted SSI: (1) the use of a drain, OR 2.3, 95% CI (1.3–3.8); (2) number of operations OR 3.4, 95% CI (2.0–6.0); (3) diabetes, OR 2.1, 95% CI (1.2–3.8); (4) congestive heart failure (CHF), OR 2.8, 95% CI (1.3–6.5); (5) site of injury tibial shaft/plateau, OR 2.3, 95% CI (1.3–4.2); and (6) site of injury, elbow, OR 2.2, 95% CI (1.1–4.7).
The risk factors for SSIs after skeletal trauma are most strongly determined by nonmodifiable factors: patient infirmity (diabetes and heart failure) and injury complexity (site of injury, number of operations, use of a drain).
Level of Evidence
Level II, prognostic study. See the Guideline for Authors for a complete description of levels of evidence.
PMCID: PMC3148392  PMID: 21161736
25.  Infirmity and Injury Complexity are Risk Factors for Surgical-site Infection after Operative Fracture Care 
Orthopaedic surgical-site infections prolong hospital stays, double rehospitalization rates, and increase healthcare costs. Additionally, patients with orthopaedic surgical-site infections (SSI) have substantially greater physical limitations and reductions in their health-related quality of life. However, the risk factors for SSI after operative fracture care are unclear.
We determined the incidence and quantified modifiable and nonmodifiable risk factors for SSIs in patients with orthopaedic trauma undergoing surgery.
Patients and Methods
We retrospectively indentified, from our prospective trauma database and billing records, 1611 patients who underwent 1783 trauma-related procedures between 2006 and 2008. Medical records were reviewed and demographics, surgery-specific data, and whether the patients had an SSI were recorded. We determined which if any variables predicted SSI.
Six factors independently predicted SSI: (1) the use of a drain, OR 2.3, 95% CI (1.3–3.8); (2) number of operations OR 3.4, 95% CI (2.0–6.0); (3) diabetes, OR 2.1, 95% CI (1.2–3.8); (4) congestive heart failure (CHF), OR 2.8, 95% CI (1.3–6.5); (5) site of injury tibial shaft/plateau, OR 2.3, 95% CI (1.3–4.2); and (6) site of injury, elbow, OR 2.2, 95% CI (1.1–4.7).
The risk factors for SSIs after skeletal trauma are most strongly determined by nonmodifiable factors: patient infirmity (diabetes and heart failure) and injury complexity (site of injury, number of operations, use of a drain).
Level of Evidence
Level II, prognostic study. See the Guideline for Authors for a complete description of levels of evidence.
PMCID: PMC3148392  PMID: 21161736

Results 1-25 (919952)