Study to prospectively evaluate reamed intramedually nails in patients with tibial fractures (S.P.R.I.N.T.): Study rationale and design

Background: Surgeons agree on the benefits of operative treatment of tibial fractures – the most common of long bone fractures – with an intramedullary rod or nail. Rates of re-operation remain high – between 23% and 60% in prior trials – and the two alternative nailing approaches, reamed or non-reamed, each have a compelling biological rationale and strong proponents, resulting in ongoing controversy regarding which is better. Methods/Design: The objective of this trial was to assess the impact of reamed versus non-reamed intramedullary nailing on rates of re-operation in patients with open and closed fractures of the tibial shaft. The study to prospectively evaluate reamed intramedullary nails in tibial fractures (S.P.R.I.N.T) was a multicenter, randomized trial including 29 clinical sites in Canada, the United States and the Netherlands which enrolled 1200 skeletally mature patients with open (Gustilo Types I-IIIB) or closed (Tscherne Types 0–3) fractures of the tibial shaft amenable to surgical treatment with an intramedullary nail. Patients received a statically locked intramedullary nail with either reamed or non-reamed insertion. The first strategy involved fixation of the fracture with an intramedullary nail following reaming to enlarge the intramedullary canal (Reamed Group). The second treatment strategy involved fixation of the fracture with an intramedullary nail without prior reaming of the intramedullary canal (Non-Reamed Group). Patients, outcome assessors, and data analysts were blinded to treatment allocation. Peri-operative care was standardized, and re-operations before 6 months were proscribed. Patients were followed at discharge, 2 weeks post-discharge, and at 6 weeks, 3, 6, 9, and 12 months post surgery. A committee, blinded to allocation, adjudicated all outcomes. Discussion: The primary outcome was re-operation to promote healing, treat infection, or preserve the limb (fasciotomy for compartment syndrome after nailing). The primary outcome was a composite comprising the following re-operations: bone grafts, implant exchanges, and dynamizations, in patients with fracture gaps less than 1 cm post intramedullary nail insertion. Infections and fasciotomies were considered events irrespective of the fracture gap. We planned a priori to conduct a subgroup analysis of outcomes in patients with open and closed fractures. S.P.R.I.N.T is the largest collaborative trial evaluating alternative orthopaedic surgical interventions in patients with tibial shaft fractures. The methodological rigor will set new benchmarks for future trials in the field and its results will have important impact on patient care. The S.P.R.I.N.T trial was registered [ID NCT00038129] and received research ethics approval (REB#99-077)

Extraskeletal Effects of Vitamin D: Potential Impact on WV Disease Morbidity and Mortality

Vitamin D is an essential nutrient and a secosteroid hormone that regulates many physiologic processes beyond calcium and bone homeostasis. These extraskeletal effects are impacted by the circulating levels of the storage form of vitamin D, 25-hydroxyvitamin D3. Levels of vitamin D can be detected after completing a simple 25(OH)D blood test. Vitamin D deficiency (\u3c 30 ng/mL) is associated with a higher risk of many chronic diseases including, but not limited to, fourteen types of cancers, type 1 and 2 diabetes mellitus, obesity, cardiovascular disease, hypertension, stroke, and asthma. This article explores the association between vitamin D deficiency and the burden of chronic diseases in West Virginia

Physician’s Ability to Manually Detect Isolated Elevation in Leg Intracompartmental Pressure.

Background: Serial physical examination is recommended for patients for whom there is a high index of suspicion for compartment syndrome. This examination is more difficult when performed on an obtunded patient and relies on the sensitivity of manual palpation to detect compartment firmness—a direct manifestation of increased intracompartmental pressure. This study was performed to establish the sensitivity of manual palpation for detecting critical pressure elevations in the leg compartments most frequently involved in clinical compartment syndrome. Methods: Reproducible, sustained elevation of intracompartmental pressure was established in fresh cadaver leg specimens. Pressures tested included 20 and 40 mm Hg (negative controls) and 60 and 80 mm Hg (considered to be consistent with a compartment syndrome). Each leg served as an internal control, with three compartments having a noncritical pressure elevation. Orthopaedic residents and faculty were individually invited to manually palpate the leg with a known compartment pressure and to answer the following questions: (1) Is there a compartment syndrome? (2) In which compartment or compartments do you believe the pressure is elevated, if at all? (3) Describe your examination findings as soft, compressible, or firm. Results: When a true-positive result was considered to be the correct detection of an elevation of intracompartmental pressures and correct identification of the compartment with the elevated pressure, the sensitivity of manual palpation was 24%, the specificity was 55%, the positive predictive value was 19%, and the negative predictive value was 63%. With increasing intracompartmental pressure, fasciotomy was recommended with a higher frequency (19% when the pressure was 20 mm Hg, 28% when it was 40 mm Hg, 50% when it was 60 mm Hg, and 60% when it was 80 mm Hg). When a true-positive result of manual palpation was considered to be an appropriate recommendation of fasciotomy, regardless of the ability of the examiner to correctly localize the compartment with the critical pressure elevation, the sensitivity was 54%,the specificity was 76%, the positive predictive value was 70%, and the negative predictive value was 63%. Conclusions: Manual detection of compartment firmness associated with critical elevations in intracompartmentalpressure is poor

Cast-Saw Burns: Evaluation of Skin, Cast, and Blade Temperatures Generated During Cast Removal

Background: The use of an oscillating saw for cast removal creates a potential for iatrogenic injury and patient discomfort. Burns and abrasions can occur from the heat created by frictional forces and direct blade contact. With use of a cadaver model system, skin temperature measurements were recorded during cast removal with an oscillating saw. Methods: Casts of uniform thickness were applied to cadavers equilibrated to body temperature. The casts were removed by a single individual while simultaneously measuring temperatures at the skin-padding interface, cast-padding interface, and the blade. Variables tested include two removal techniques, two casting materials (fiberglass and plaster), and two cast-padding thicknesses. Results: A poor removal technique (the cast saw blade never leaving the cast material during cutting), fiberglass casting material, and thinner cast padding resulted in significantly higher skin temperatures. The poor technique increased skin temperatures by an average of 5.0°C (p \u3c 0.05). Fiberglass casting materials increased skin temperatures by an average of 7.4°C (p \u3c 0.05). Four layers of cast padding compared with two layers decreased skin temperatures by 8.0°C (p \u3c 0.05). Conclusions: The highest skin temperatures were recorded for fiberglass casts with two layers of padding. The lowest skin temperatures were recorded for plaster casts with four layers of padding. Four layers of cast padding compared with two layers significantly reduced skin temperatures for both plaster and fiberglass casts. Clinical Relevance: A routine assessment of the layers of padding and the type of cast material prior to splitting casts with an oscillating saw can help clinicians to identify cast removal conditions with a higher risk for causing patient discomfort, abrasions, or burns

Defining Bone Health and Fracture Risk in West Virginia: The World Health Organization FRAX® Assessment Tool

This article highlights the expanding burden of osteoporosis in West Virginia. WV ranks second nationally in the percentage of its population that is ≥ 65 years of age. Our older population increases the risk of osteoporosis and fracture; the most recent data indicates that 77% of our women age 50 and older have osteoporosis or low bone mass. The lifetime risk of osteoporotic related fracture is alarming and occurs in 50% of females and 25% of males age 50 and older. The risk of osteoporosis related hip fracture in women is equal to the combined risk of breast, uterine or ovarian cancer with the annual risk of osteoporotic fracture greater than the combined risk of breast cancer, stroke and heart attack. Detecting individuals at risk for fracture has been aided by an internationally validated fracture prediction tool from the World Health Organization -- FRAX®. The FRAX® tool can be incorporated into protocols to help minimize barriers to effective osteoporosis screening and treatment in WV

Preventing Falls with Vitamin D

Falls are the number one cause for injury-related morbidity and mortality in West Virginia’s seniors. Multiple independent variables contribute to the risk of a fall: previous falls, alterations in balance and vision, impairments in gait and strength, and medications most highly correlate with the risk for a fall. Vitamin D supplementation is emerging as an easy, safe and well-tolerated fall reduction/prevention strategy due to the beneficial effects on the musculoskeletal system with improvements in strength, function and navigational abilities. From meta-analysis data, maximal fall reduction benefit in seniors is achieved when correcting vitamin D deficiency and when using adjunctive calcium supplementation. It is therefore recommended that practitioners in our state screen for fall risks and consider the addition of supplementation protocols that provide sufficient vitamin D and calcium to our seniors

Improving the Pharmacologic Management of Patients after Osteoporotic Hip Fractures

Abstract Background Osteoporotic hip fractures have become an increasingly common healthcare burden with significant morbidity and mortality in the geriatric population. Pharmacological management of the underlying osteoporosis is critical. Our objective is to determine the percentage of patients older than 65 who receive pharmacologic treatment of osteoporosis within six months after a fragility fracture at Cabell Huntington Hospital. Methods Data was extracted from medical records for patients age 65 or older who sustained a hip fracture during June 2013 - March 2015. Patients who received any form of pharmacologic treatment within six months after their fractures were identified. All analyses were performed using SAS version 9.3 (SAS Institute, Cary, North Carolina). Results Among the 193 patients who met the inclusion criteria, 26% (n=50) received pharmacologic treatment within six months after fracturing versus 74% (n=143) who did not receive any type of pharmacologic therapy after the fracture. Female was the predominant gender in pharmacologic treatment group (74% vs 71%). Mean age was 81 years old in both groups (81±9 vs 82±8), mean BMI was 25 in both groups (25±5 vs 25±6). There was no significant difference in pharmacologic management when the patients were stratified according to age group. Conclusion Patients were pharmacologically undertreated after an osteoporotic hip fracture, regardless of the age of fracture presentation. Due to potential benefits of pharmacologic treatment after osteoporotic hip fracture, treatment should be initiated prior to discharge, if possible. If this is not feasible for the patient, specific and detailed instructions should be given to the patient’s primary care physician, or endocrinologist if medically complicated, for initiating therapy and proper management of the patient

Antibiotic-Like Actions of Vitamin D

Vitamin D is a secosteroid hormone that has expanding importance for a healthy lifestyle and disease prevention. A multitude of studies have highlighted that vitamin D acts not only in bone and calcium homeostasis but is critically important for human immunity. The discovery that the storage form of vitamin D (25-hydroxyvitamin D3) can be locally converted to the active form (1,25-hydroxyvitamin D3) in immune cells, epithelial cells and numerous other non-renal tissues highlights the importance of maintaining sufficient stores. When responding to a specific external stimulus, like bacterial invasion, intracrine synthesis of active vitamin D has the ability to regulate gene expression providing a specific response and directing cellular actions. These responses include the generation of antimicrobial peptides with production of these peptides dependent on vitamin D status. Vitamin D deficiency is associated with an increased rate of infection. This paper highlights the antibiotic like actions of vitamin D and importance of vitamin D sufficiency

Lamina Spreader Technique Improves Debridement of Loose Bone and Cement in Total Knee Arthroplasty

Abstract Loose bone and cement can promote polyethylene wear that may lead to failure in total knee arthroplasty. The authors propose a technique to enhance the debridement of loose bodies by distracting the cemented components with a lamina spreader following standard debridement with pulsatile lavage. Cement and bone/soft tissue debris was recovered from 51 consecutive primary total knee arthroplasty patients. This technique facilitated the removal of hidden debris in 80% of patients (41/51). On average, 2.6 fragments measuring 158 mm3 were removed per patient. The authors advocate that distraction with a lamina spreader be used to reduce potential sources of wear

Smartphone Mobile Application to Enhance Diagnosis of Skin Cancer: A Guide for the Rural Practitioner

Primary care physicians occupy a vital position to impact many devastating conditions, especially those dependent upon early diagnosis, such as skin cancer. Skin cancer is the most common cancer in the United States and despite improvements in skin cancer therapy, patients with a delay in diagnosis and advanced disease continue to have a grave prognosis. Due to a variety of barriers, advanced stages of skin cancer are more prominent in rural populations. In order to improve early diagnosis four things are paramount: increased patient participation in prevention methods, establishment of screening guidelines, increased diagnostic accuracy of malignant lesions, and easier access to dermatologists. Recent expansion in smartphone mobile application technology offers simple ways for rural practitioners to address these problems. More than 100,000 health related applications are currently available, with over 200 covering dermatology. This review will evaluate the newest and most useful of those applications offered to enhance the prevention and early diagnosis of skin cancer, particularly in the rural population