Macmillanlohse7059

Disrupted blood supply has been proposed as an underlying cause for delayed union in tibial shaft fractures (OTA/AO 42). Although tibial blood supply has been qualitatively evaluated, quantitative studies are lacking. The purpose of this project was to quantify the relative contribution of the endosteal supply to the tibial diaphysis.

The superficial femoral artery of 8 fresh frozen cadaveric matched pair lower extremities was cannulated. The nutrient artery was ligated at its proximal branch point in experimental limbs. Pregadolinium and postgadolinium enhanced magnetic resonance imaging was performed with high resolution fat-suppressed ultrashort echo time magnetic resonance imaging sequences. Perfusion was assessed in 3 zones (outer, central, and inner cortex) for the proximal, middle, and distal diaphysis, respectively, using custom software to quantify and compare signal intensity between experimental and control limbs.

On average, the endosteal system supplied 91.4% (±3.9%) of the cortex and was the predominant blood supply for the inner, central, and outer thirds. The dominance of the endosteal contribution was most pronounced in the inner two-third of the cortex, with more than 97% loss of perfusion. Disruption of the nutrient artery also resulted in 76.3% (±11.2%) loss of perfusion of the outer one-third of the cortex.

This quantitative study revealed a predominance of endosteal blood supply to all areas (inner, middle, and outer thirds) of the tibial diaphyseal cortex. To prevent delayed bone healing, surgeons should take care to preserve the remaining periosteal vascular network in fracture patterns in which the nutrient artery has likely been disrupted.

This quantitative study revealed a predominance of endosteal blood supply to all areas (inner, middle, and outer thirds) of the tibial diaphyseal cortex. To prevent delayed bone healing, surgeons should take care to preserve the remaining periosteal vascular network in fracture patterns in which the nutrient artery has likely been disrupted.

The primary objective of this study was to identify differences in treatment approach for isolated, displaced midshaft clavicle fractures in adolescent patients 15 to 18 years of age at adult versus pediatric hospitals. The secondary objective of this study was to identify factors associated with surgical treatment of these fractures in this age group.

Retrospective cohort study SETTING Two adult and one pediatric tertiary care referral hospitalsPatients/Participants Adolescent patients 15 to 18 years of age with isolated, displaced midshaft clavicle fractures treated at two adult tertiary care referral hospitals and one pediatric tertiary care referral hospital were identified. A total of 214 patients, 105 from the adult hospitals and 109 from the pediatric hospital, were included.

Nonoperative versus surgical treatment of clavicle fractures MAIN OUTCOME MEASUREMENT Surgical treatment RESULTS Multivariable logistic regression analysis showed that superior-inferior fracture displacement (OR 1.13, 95% CI 1.06 to 1.20), dominant upper extremity injury (OR 2.60, 95% CI 1.19 to 5.67), and treatment at an adult hospital (OR 5.28, 95% CI 2.28 to 12.2) were independently associated with surgical treatment of adolescent displaced midshaft clavicle fractures.

After controlling for relevant demographic and fracture characteristics, adolescent patients treated at adult hospitals for displacement midshaft clavicle fractures have more than 5 times the odds of surgical treatment than those treated at a pediatric hospital. Significant practice variation across institutions reflects ongoing controversy in surgical indications and underscores the need for high quality prospective outcomes studies.

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

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

Patients who undergo trauma-related amputation are rarely screened for low bone mineral density(BMD) in the post-trauma setting. The current study aims to correlate femoral neck Hounsfield units(HU) measured on CT scan to dual-energy x-ray absorptiometry(DEXA) T-scores allowing evaluation of BMD over time after lower extremity trauma-related amputation.

Retrospective Cohort Study SETTING United States Military Trauma Referral Center PATIENTS Military combat-related lower extremity amputees with both DEXA and CT scans within six months of each other.

None MAIN OUTCOME MEASURES Correlation between femoral neck comprehensive mean HU and BMD, and HU threshold for low BMD.

Regression model correlation(r) between CT HU and DEXA T-score was r=0.84(95%CI 0.52-0.94) and r=0.81(95%CI 0.57-0.92) when CT imaging was separated from DEXA by less than four and five months, respectively. Beyond five months separation, correlation decreased to r=0.60(95%CI 0.29-0.80). Using a receiver operator characteristic curve for mean comprehensive HU to determine low BMD with four-month cut-off, a threshold of 151 HUs was 97% sensitive and 84% specific to identify low BMD, while 98 HUs was 100% sensitive and 100% specific to identify osteoporosis.

Using opportunistic CT, clinicians can reliably estimate BMD in trauma-related amputees. This information will inform providers making decisions regarding weightbearing and bisphosphonate therapy to limit further loss. Future phases of this study will aim to use this correlation to study the effects of weightbearing advancement timing, bisphosphonate therapy, and interventions on the natural history of bone density after amputation.

Diagnostic Level IV. see more See Instructions for Authors for a complete description of levels of evidence.

Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

To evaluate the quality of research and reporting of randomized controlled trials comparing the use of reamed and unreamed intramedullary nails for tibial fractures with validated scoring systems.

PubMed using the search terms "tibia" AND "reamed OR unreamed" AND "intramedullary OR nail." Filters were applied for the years 1991-2019, full articles, human subjects, and English language.

Inclusion criteria were (1) prospective and randomized trials, (2) studies reported >80% follow-up, and (3) articles amenable to scoring with the chosen scoring systems. Exclusion criteria were (1) skeletally immature patients or (2) incomplete data sets.

Articles were assessed with the Coleman Methodology Score, the Consolidated Standards of Reporting Trials systems, and Cowan's Categorical Rating by 2 independent observers.

Scores for individual articles were averaged for the 2 observers. The total and subcategory scores for all included articles were also averaged with SD from both observers. Categories from the 2 grading systems with deficient reporting were measured as a percentage based on grading from both observers.