[Show abstract][Hide abstract] ABSTRACT: BACKGROUND The management of open fractures requires wound irrigation and debridement to remove contaminants, but the effectiveness of various pressures and solutions for irrigation remains controversial. We investigated the effects of castile soap versus normal saline irrigation delivered by means of high, low, or very low irrigation pressure. METHODS In this study with a 2-by-3 factorial design, conducted at 41 clinical centers, we randomly assigned patients who had an open fracture of an extremity to undergo irrigation with one of three irrigation pressures (high pressure [>20 psi], low pressure [5 to 10 psi], or very low pressure [1 to 2 psi]) and one of two irrigation solutions (castile soap or normal saline). The primary end point was reoperation within 12 months after the index surgery for promotion of wound or bone healing or treatment of a wound infection. RESULTS A total of 2551 patients underwent randomization, of whom 2447 were deemed eligible and included in the final analyses. Reoperation occurred in 109 of 826 patients (13.2%) in the high-pressure group, 103 of 809 (12.7%) in the low-pressure group, and 111 of 812 (13.7%) in the very-low-pressure group. Hazard ratios for the three pairwise comparisons were as follows: for low versus high pressure, 0.92 (95% confidence interval [CI], 0.70 to 1.20; P = 0.53), for high versus very low pressure, 1.02 (95% CI, 0.78 to 1.33; P = 0.89), and for low versus very low pressure, 0.93 (95% CI, 0.71 to 1.23; P = 0.62). Reoperation occurred in 182 of 1229 patients (14.8%) in the soap group and in 141 of 1218 (11.6%) in the saline group (hazard ratio, 1.32, 95% CI, 1.06 to 1.66; P = 0.01). CONCLUSIONS The rates of reoperation were similar regardless of irrigation pressure, a finding that indicates that very low pressure is an acceptable, low-cost alternative for the irrigation of open fractures. The reoperation rate was higher in the soap group than in the saline group.
Full-text · Article · Oct 2015 · New England Journal of Medicine
[Show abstract][Hide abstract] ABSTRACT: Despite the fact that orthopaedic trauma injuries represent a serious cause of mortality and morbidity worldwide, there are few data in low-middle income countries quantifying the burden of fractures and describing current treatment practices. To address this critical knowledge gap, a large multinational prospective observational study of 40,000 patients with musculoskeletal trauma in Africa, Asia, and Latin America is proposed. The International Orthopaedic Multicentre Study in Fracture Care (INORMUS) study seeks to determine the incidence of major complications (mortality, reoperation, and infection) within 30 days after a musculoskeletal injury and to determine patient, treatment, and system factors associated with these major complications in low-middle income countries. This study coincides with the World Health Organization's Global Road Traffic Safety Decade (2011-2020) and other international efforts to reduce the burden of injury on developing populations. Insight gained from the INORMUS study will not only inform the global burden of orthopaedic trauma but also drive the development of future randomized trials to evaluate simple solutions and practical interventions to decrease deaths and improve the quality of life for trauma patients worldwide.
[Show abstract][Hide abstract] ABSTRACT: Objectives:
The objectives of this systematic review and meta-analyses are: 1) to estimate the prevalence of hypovitaminosis D in fracture patients and 2) to summarize the available evidence on the efficacy of vitamin D supplementation in fracture patients.
A comprehensive search of the MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases was conducted. Conference abstracts from relevant meetings were also searched.
We included studies that investigate vitamin D insufficiency or examine the effect of vitamin D supplementation on 25(OH)D serum levels in fracture patients.
Two authors independently extracted data using a pre-designed form.
We performed a pooled analysis to determine the prevalence of post-fracture hypovitaminosis D and mean post-fracture 25(OH)D levels. We present detailed summaries of each of the studies evaluating the impact of vitamin D supplementation.
The weighted pooled prevalence of hypovitaminosis D was 70.0% (95% CI: 63.7-76.0%, I = 97.7). The mean post-fracture serum 25(OH)D was 19.5 ng/ml. The studies that evaluated the efficacy of vitamin D supplementation suggest that vitamin D supplementation safely increases serum 25(OH)D levels. Only one meeting abstract showed a trend towards reduced risk of nonunion following a single large loading dose of vitamin D.
This review found a high prevalence of hypovitaminosis D in fracture patients and that vitamin D supplementation at a range of doses safely increases 25(OHD) serum levels. To date, only one pilot study published as a meeting abstract has demonstrated a trend towards improved fracture healing with vitamin D supplementation.
Level of evidence:
No preview · Article · Sep 2015 · Journal of Orthopaedic Trauma
[Show abstract][Hide abstract] ABSTRACT: Intimate partner violence (IPV) is a serious global issue that results in a large number of injuries and deaths among women. Educating clinicians about IPV can help providers identify, prevent, and treat victims, and, ultimately, improve care for victims of abuse. We sought to determine the effect of a half-day educational course on IPV for orthopaedic surgical trainees on knowledge and attitudes.
We asked (1) whether a half-day educational course on IPV can improve orthopaedic surgical trainees' knowledge and (2) attitudes regarding IPV; and (3) whether a course on IPV can be accepted and viewed as valuable by trainees?
Using published research on IPV in patients with musculoskeletal injuries, we developed a half-day educational course. The curriculum included lectures and discussion regarding the basics of IPV, the current state of IPV research, what to do when a patient is a victim or perpetrator, and the orthopaedic surgeon's role in recognizing, preventing, and assisting with IPV. All 33 course participants (30 men and three women), all orthopaedic surgical trainees, completed a questionnaire that included general true or false or agree or disagree statements regarding their knowledge, attitudes, and practices of IPV in the musculoskeletal setting; the questionnaire also included a knowledge test of 25 true or false statements. The questionnaire was administered immediately before, immediately after, and 3 months after the course; 76% (25 of 33) took the test immediately after the course and 82% (27 of 33) completed the test at 3 months. Participant knowledge scores were compared across the three different times to determine the effect of the course.
Participants increased their knowledge after the course, and the increased knowledge was retained at retesting at 3 months; the mean percentage of correct answers before the course was 57%, which increased to 73% after the course, and was 68% 3 months later (F = 9.505; p = 0.001). Before the course, most of the course participants (30 of 32; 94%) agreed that IPV is an important issue; agreement increased to 100% immediately after the course. The largest change in attitude was in response to the statement: "I am skeptical that the health care system has the resources to screen for IPV." Before the course, 53% (17 of 32) of trainees endorsed this statement, but the percent decreased to 36% (nine of 25) after the course and remained low at 33% (nine of 27), at the 3-month test.
Our findings show that a short course on IPV in patients with musculoskeletal injuries led to an improvement and retention of knowledge 3 months after the course. Based on our findings, we recommend that IPV education be integrated in training programs for orthopaedic surgeons. Future projects should focus on developing and implementing a sustainable education program that can affect practice for healthcare professionals and trainees in multiple clinical settings.
No preview · Article · Apr 2015 · Clinical Orthopaedics and Related Research
[Show abstract][Hide abstract] ABSTRACT: In the previous article (Network Meta-analysis: Users' Guide for Surgeons-Part I, Credibility), we presented an approach to evaluating the credibility or methodologic rigor of network meta-analyses (NMA), an innovative approach to simultaneously addressing the relative effectiveness of three or more treatment options for a given medical condition or disease state. In the second part of the Users' Guide for Surgeons, we discuss and demonstrate the application of criteria for determining the certainty in effect sizes and directions associated with a given treatment option through an example pertinent to clinical orthopaedics.
No preview · Article · Apr 2015 · Clinical Orthopaedics and Related Research
[Show abstract][Hide abstract] ABSTRACT: Conventional meta-analyses quantify the relative effectiveness of two interventions based on direct (that is, head-to-head) evidence typically derived from randomized controlled trials (RCTs). For many medical conditions, however, multiple treatment options exist and not all have been compared directly. This issue limits the utility of traditional synthetic techniques such as meta-analyses, since these approaches can only pool and compare evidence across interventions that have been compared directly by source studies. Network meta-analyses (NMA) use direct and indirect comparisons to quantify the relative effectiveness of three or more treatment options. Interpreting the methodologic quality and results of NMAs may be challenging, as they use complex methods that may be unfamiliar to surgeons; yet for these surgeons to use these studies in their practices, they need to be able to determine whether they can trust the results of NMAs. The first judgment of trust requires an assessment of the credibility of the NMA methodology; the second judgment of trust requires a determination of certainty in effect sizes and directions. In this Users' Guide for Surgeons, Part I, we show the application of evaluation criteria for determining the credibility of a NMA through an example pertinent to clinical orthopaedics. In the subsequent article (Part II), we help readers evaluate the level of certainty NMAs can provide in terms of treatment effect sizes and directions.
No preview · Article · Apr 2015 · Clinical Orthopaedics and Related Research
[Show abstract][Hide abstract] ABSTRACT: Importance of the TopicMore than 650,000 ankle sprains present to emergency departments in the United States for treatment every year . The vast majority of these sprains are injuries to the lateral ligament complex resulting from a forceful inversion of the ankle joint during physical activity . The impact of a lateral ligament complex sprain is experienced through acute pain and swelling, several weeks of acute disability resulting in time lost from work or other activities, and in as many as 20% of patients, chronic instability of the ankle joint [1, 7].Anatomically, lateral ligament sprains are almost always localized to the anterior talofibular ligament. The calcaneofibular ligament is also involved in 50% to 75% of sprains . The third ligament of the lateral ligament complex – the posterior talofibular ligament – is rarely involved. In cases of chronic instability, anatomic reconstructive procedures (as originally described by Brostrom  and subsequently modified) fre ...
No preview · Article · Oct 2014 · Clinical Orthopaedics and Related Research
[Show abstract][Hide abstract] ABSTRACT: Background:
The World Health Organization estimates that more than 15% of the global burden of road traffic trauma is in India. We performed an image-based survey of 3 major roadways in New Delhi, India, to evaluate collision-prone vehicle and pedestrian behaviors.
We used a cross-sectional survey design with photograph- and video-based data collection. The study was performed at 3 purposively sampled high traffic volume roadways in New Delhi, India. The authors reviewed preliminary photographs and came to a consensus pertaining to the definition and criteria for dangerous and collision-prone behaviors. Analysis was descriptive and was based on frequency data.
A total of 11,214 subjects were evaluated. Eighty-six percent were vehicles (n = 9624), whereas the remaining 14% were pedestrians (n = 1572). In 99% of the frames, 1 or more predefined behavioral infraction was identified, with a total of 21% (n = 2392) of subjects committing these infractions. Specifically, 15% of all vehicles (n = 1468) and 59% of all pedestrians (n = 924) displayed a risk-taking infraction.
Road users in New Delhi, India, engage in unacceptably high rates of collision-prone behavior. There is a need for interventions that will improve the behaviors of road users.
No preview · Article · Jun 2014 · Journal of orthopaedic trauma
[Show abstract][Hide abstract] ABSTRACT: Emotional intelligence (EI) is the ability to understand and manage emotions in oneself and others. It was originally popularized in the business literature as a key attribute for success that was distinct from cognitive intelligence. Increasing focus is being placed on EI in medicine to improve clinical and academic performance. Despite the proposed benefits, to our knowledge, there have been no previous studies on the role of EI in orthopedic surgery. We evaluated baseline data on EI in a cohort of orthopedic surgery residents.
We asked all orthopedic surgery residents at a single institution to complete an electronic version of the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT). We used completed questionnaires to calculate total EI scores and 4 branch scores. Data were analyzed according to a priori cutoff values to determine the proportion of residents who were considered competent on the test. Data were also analyzed for possible associations with age, sex, race and level of training.
Thirty-nine residents (100%) completed the MSCEIT. The mean total EI score was 86 (maximum score 145). Only 4 (10%) respondents demonstrated competence in EI. Junior residents (p = 0.026), Caucasian residents (p = 0.009) and those younger than 30 years (p = 0.008) had significantly higher EI scores.
Our findings suggest that orthopedic residents score low on EI based on the MSCEIT. Optimizing resident competency in noncognitive skills may be enhanced by dedicated EI education, training and testing.
Preview · Article · Apr 2014 · Canadian journal of surgery. Journal canadien de chirurgie
[Show abstract][Hide abstract] ABSTRACT: Assessing fracture healing in clinical trials is subjective. The new Function IndeX for Trauma (FIX-IT) score provides a simple, standardized approach to assess weight-bearing and pain in patients with lower extremity fractures. We conducted an initial validation of the FIX-IT score.
We conducted a cross-sectional study involving 50 patients with lower extremity fractures across different stages of healing to evaluate the reliability and preliminary validity of the FIX-IT score. Patients were independently examined by 2 orthopedic surgeons, 1 orthopedic fellow, 2 orthopedic residents and 2 research coordinators. Patients also completed the Short Form-36 version 2 (SF-36v2) questionnaire, and convergent validity was tested with the SF-36v2.
For interrater reliability, the intraclass correlation coefficents ranged from 0.637 to 0.915. The overall interrater reliability for the total FIX-IT score was 0.879 (95% confidence interval 0.828-0.921). The correlations between the FIX-IT score and the SF-36 ranged from 0.682 to 0.770 for the physical component summary score, from 0.681 to 0.758 for the physical function subscale, and from 0.677 to 0.786 for the role-physical subscale.
The FIX-IT score had high interrater agreement across multiple examiners. Moreover, FIX-IT scores correlate with the physical scores of the SF-36. Although additional research is needed to fully validate FIX-IT, our results suggest the potential for FIX-IT to be a reliable adjunctive clinician measure to evaluate healing in lower extremity fractures.
Diagnostic Study Level I.
Preview · Article · Oct 2013 · Canadian journal of surgery. Journal canadien de chirurgie
[Show abstract][Hide abstract] ABSTRACT: Background: Approximately one-third of injured women presenting to fracture clinics have experienced some form of intimate partner violence in the past year. The aim of the current study was to determine patients’ perceptions on screening for intimate partner violence during visits to a surgical fracture clinic.
Methods: We conducted a cross-sectional study to evaluate patients’ perceptions and opinions on screening for inti- mate partner violence in an orthopaedic fracture clinic. Eligible patients anonymously completed a self-reported written questionnaire, which included questions on patient demographics, attitudes toward intimate partner violence in general, the acceptability of screening for intimate partner violence in an orthopaedic fracture clinic, and opinions on how, when, and by whom the screening should be conducted.
Results: The study included 750 patients (421 male and 329 female) at five clinical sites in Canada and the Netherlands. The majority (554, 73.9%) of the respondents either ‘‘agreed’’ or ‘‘strongly agreed’’ that the fracture clinic was a good place for health-care providers to ask about intimate partner violence. The majority (671, 89.5%) also agreed that health- care providers should screen for intimate partner violence by means of face-to-face interactions rather than other, more passive methods. Increased openness to screening was significantly associated with female sex, higher income, and higher education (F3595 = 21.950, p < 0.001).
Conclusions: Our findings demonstrated that the majority of patients endorse active screening for intimate partner violence in orthopaedic fracture clinics.
Full-text · Article · Jul 2013 · The Journal of Bone and Joint Surgery
[Show abstract][Hide abstract] ABSTRACT: Background Intimate partner violence (IPV) is the leading cause of non-fatal injury to women worldwide. Musculoskeletal injuries, which are often seen by orthopaedic surgeons, are the second most common manifestation of IPV. We aimed to establish the 12-month and lifetime prevalence of IPV in women presenting to orthopaedic fracture clinics. Methods The PRAISE team of 80 investigators did a cross-sectional study of a consecutive sample of 2945 female participants at 12 orthopaedic fracture clinics in Canada, the USA, the Netherlands, Denmark, and India. Participants who met the eligibility criteria anonymously answered direct questions about physical, emotional, and sexual IPV, and completed two previously developed questionnaires (Women Abuse Screening Tool [WAST] and Partner Violence Screen [PVS]). We did a multivariable logistic regression analysis to investigate the risk factors associated with IPV. Findings The overall response rate was 85% (2344 of 2759 patients provided informed consent). One in six women (455/2839, 16·0%, 95% CI 14·7–17·4%) disclosed a history of IPV within the past year, and one in three (882/2550, 34·6%, 32·8–36·5%) had experienced IPV in their lifetime. 49 women (1·7%, 1·3–2·2%) attended their clinic visit as a direct consequence of IPV, only seven of whom (14%) had ever been asked about IPV in a health-care setting. Women in short-term relationships (OR 0·584, 99% CI 0·396–0·860, p=0·0001) were at increased risk of IPV and physical abuse in the past 12 months in this study. Compared with women in Canada and the USA, those in the Netherlands and Denmark were at reduced risk of any abuse in the past 12 months, physical abuse in lifetime, and any abuse in lifetime (OR 0·595, 99% CI 0·427–0·830, p<0·0001; 0·630, 0·445–0·890, p=0·001; and 0·464, 0·352–0·612, p<0·0001, respectively). Interpretation PRAISE is the largest prevalence study done so far in orthopaedics. Orthopaedic surgeons should be confi dent in the assumption that one in six women have a history of physical abuse, and that one in 50 injured women will present to the clinic as a direct result of IPV. Our fi ndings warrant serious consideration for fracture clinics to improve identifi cation of, respond to, and provide referral services for, victims of IPV.
[Show abstract][Hide abstract] ABSTRACT: Objective:
The assessment of fracture healing following intertrochanteric fracture fixation is highly variable with no validated standards. Agreement with respect to fracture healing following surgery is important for optimal patient management. The purpose of this study was to (1) assess reliability of intertrochanteric fracture healing assessment and (2) determine if a novel radiographic scoring system for hip fractures improves agreement between radiologists and orthopedic surgeons.
Materials and methods:
A panel of three radiologists and three orthopedic surgeons assessed fracture healing in 150 cases of intertrochanteric fractures at two separate time points to determine inter-rater and intra-rater agreement. Reviewers, blinded to the time after injury, first subjectively assessed overall healing using frontal and lateral radiographs for each patient at a single time point. Reviewers then scored each fracture using a Radiographic Union Score for Hip (RUSH) form to determine whether this improves agreement regarding hip fracture healing.
Inter-rater agreement for the overall subjective impression of fracture healing between reviewer groups was only fair (intraclass coefficient [ICC] = 0.34, 95 % CI: 0.11-0.52. Use of the RUSH score improved overall agreement between groups to substantial (ICC = 0.66, 95 % CI: 0.53-0.75). Across reviewers, healing of the medial cortex and overall RUSH score itself demonstrated high correlations with overall perceptions of healing (r = 0.53 and r = 0.72, respectively).
The RUSH score improves agreement of fracture healing assessment between orthopedic surgeons and radiologists, offers a systematic approach to evaluating intertrochanteric hip fracture radiographs, and may ultimately provide prognostic information that could predict healing outcomes in patients with femoral neck fractures.
No preview · Article · Apr 2013 · Skeletal Radiology
[Show abstract][Hide abstract] ABSTRACT: Background
Intimate Partner Violence (IPV) is a major health issue that involves any physical, sexual or psychological harm inflicted by a current or former partner. Musculoskeletal injuries represent the second most prevalent clinical manifestation of IPV. Health care professionals, however, rarely screen women for IPV. Using qualitative methods, this study aimed to explore the perceived barriers to IPV screening and potential facilitators for overcoming these barriers among orthopaedic surgeons and surgical trainees.
We conducted three focus groups with orthopaedic surgeons, senior surgical trainees, and junior surgical trainees. A semi-structured focus group guide was used to structure the discussions. Transcripts and field notes from the focus groups were analyzed using the qualitative software program N’Vivo (version 10.0; QSR International, Melbourne, Australia). To further inform our focus group findings and discuss policy changes, we conducted interviews with two opinion leaders in the field of orthopaedics. Similar to the focus groups, the interviews were digitally recorded and transcribed, and then analyzed.
In the analysis, four categories of barriers were identified: surgeon perception barriers; perceived patient barriers; fracture clinic barriers and orthopaedic health care professional barriers. Some of the facilitators identified included availability of a crisis team; development of a screening form; presence of IPV posters or buttons in the fracture clinic; and the need for established policy or government support for IPV screening. The interviewees identified the need for: the introduction of evidence-based policy aiming to increase awareness about IPV among health care professionals working within the fracture clinic setting, fostering local and national champions for IPV screening, and the need to generate change on a local level.
There are a number of perceived barriers to screening women in the fracture clinic for IPV, many of which can be addressed through increased education and training, and additional resources in the fracture clinic. Orthopaedic health care professionals are supportive of implementing an IPV screening program in the orthopaedic fracture clinic.