Characterization of the inflammatory response to four commercial bone graft substitutes using a murine biocompatibility model

Bone grafting is utilized in nearly all orthopedic subspecialties and in most anatomic regions. Bone graft substitutes have the potential to offer similar efficacy as autogenous grafts without the morbidity of harvest. Several studies have noted the efficacy of new-generation bone substitute products, but few studies have evaluated their safety. This study characterizes and quantifies the inflammatory reaction to four different commercially available bone graft substitutes, which were examined using the in vivo murine air pouch biocompatibility model. One coralline hydroxyapatite product was chosen as an example of a purely osteoconductive material. Three demineralized bone matrix products were chosen to represent products that are both osteoconductive and osteoinductive. Samples were implanted in a murine air pouch and harvested after 14 days in situ. Pouch fluid was extracted, mRNA isolated, and reverse transcription polymerase chain reactions carried out to detect interleukin-1 gene expression as a marker for inflammation. In addition, multiple histological characteristics were examined to quantify cellular responses to the implanted materials. All bone graft substitutes induced a significant inflammatory response compared with negative controls. Histology and polymerase chain reaction data indicated that the level of inflammatory reaction was elevated in materials with a higher demineralized bone matrix to carrier proportion. The hydroxyapatite product generated a low inflammatory reaction. In conclusion, this study used an in vivo model of biocompatibility to demonstrate that a significant inflammatory reaction occurs when using implanted bone graft substitutes. When choosing a bone grafting method, surgeons should consider both the efficacy and safety of methods and materials used. Further studies are necessary to determine the ideal bone graft material to maximize efficacy while minimizing morbidity

Reimagining the Path of an Unmatched Orthopaedic Residency Application: A Survey of Program Directors

BACKGROUND: Few evidence-based suggestions are available to help applicants and mentors improve reapplication outcomes. We sought to provide program directors\u27 (PDs) perspectives on actionable steps to improve reapplicants\u27 chances for a match. METHODS: The PDs were asked to rank positions unmatched applicants can pursue, steps these applicants can take for the next application cycle, and reasons why reapplicants do not match. RESULTS: Responses from 66 of 123 PDs were received (53.6% response rate). Obtaining new recommendation letters and rotating with orthopaedics were the highest 20 ranked steps unmatched applicants can take. No curriculum vitae (CV) improvement, poor interview, and poor letters of recommendation were the most important reasons hindering applicants from matching when reapplying. CONCLUSIONS: Steps reapplicants could prioritize include obtaining new recommendation letters, rotating in orthopaedics, and producing new research items. CV strengthening and improving interview skills address the 2 main reasons why unmatched applicants failed in subsequent attempts. LEVEL OF EVIDENCE: Level IV

Short cephalomedullary nail toggle: a closer examination

Objectives: In patients with wide femoral canals, an undersized short nail may not provide adequate stability, leading to toggling of the nail around the distal interlocking screw and subsequent loss of reduction. The purpose of this study was to identify risk factors associated with nail toggle and to examine whether increased nail toggle is associated with increased varus collapse. Design: Retrospective cohort study. Setting: Level 1 and level 3 trauma center. Patients/Participants: Seventy-one patients with intertrochanteric femur fractures treated with short cephalomedullary nails (CMN) from October 2013 to December 2017. Intervention: Short CMN. Main Outcome Measurements: Nail toggle and varus collapse were measured on intraoperative and final follow-up radiographs. Risk factors for nail toggle including demographics, fracture classification, quality of reduction, Dorr type, nail/canal diameter ratio, lag screw engaging the lateral cortex, and tip-apex distance (TAD) were recorded. Results: On multivariate regression analysis, shorter TAD (P = .005) and smaller nail/canal ratio (P \u3c .001) were associated with increased nail toggle. Seven patients (10%) sustained nail toggle \u3e4 degrees. They had a smaller nail/canal ratio (0.54 vs 0.74, P \u3c .001), more commonly Dorr C (57% vs 14%, P = .025), lower incidence of lag screw engaging the lateral cortex (29% vs 73%, P = .026), shorter TAD (13.4 mm vs 18.5 mm, P = .042), and greater varus collapse (6.2 degrees vs 1.3 degrees, P \u3c .001) compared to patients with nail toggle \u3c 4 degrees. Conclusions: Lower percentage nail fill of the canal and shorter TAD are risk factors for increased nail toggle in short CMNs. Increased nail toggle is associated with increased varus collapse

Use of the Behavior Assessment Tool in 18 Pilot Residency Programs

Background: The purpose of this study was to determine the feasibility and evaluate the effectiveness of the American Board of Orthopaedic Surgery Behavior Tool (ABOSBT) for measuring professionalism. Methods: Through collaboration between the American Board of Orthopaedic Surgery and American Orthopaedic Association\u27s Council of Residency Directors, 18 residency programs piloted the use of the ABOSBT. Residents requested assessments from faculty at the end of their clinical rotations, and a 360° request was performed near the end of the academic year. Program Directors (PDs) rated individual resident professionalism (based on historical observation) at the outset of the study, for comparison to the ABOSBT results. Results: Nine thousand eight hundred ninety-two evaluations were completed using the ABOSBT for 449 different residents by 1,012 evaluators. 97.6% of all evaluations were scored level 4 or 5 (high levels of professional behavior) across all of the 5 domains. In total, 2.4% of all evaluations scored level 3 or below reflecting poorer performance. Of 431 residents, the ABOSBT identified 26 of 32 residents who were low performers (2 or more \u3c level 3 scores in a domain) and who also scored below expectations by the PD at the start of the pilot project (81% sensitivity and 57% specificity), including 13 of these residents scoring poorly in all 5 domains. Evaluators found the ABOSBT was easy to use (96%) and that it was an effective tool to assess resident professional behavior (81%). Conclusions: The ABOSBT was able to identify 2.4% low score evaluations ( Level of Evidence: Level II

Anatomy, Back, Sacral Vertebrae

The vertebral column, or spine, is composed of 33 vertebrae. These vertebrae play an essential role in protecting the spinal cord and the spinal nerves. They serve as a support for the head, neck, thorax, abdomen, and pelvis, while also allowing for flexibility and mobility through the presence of intervertebral discs and facet joints without compromising their supportive function. The spine consists of multiple segments. These are the: Cervical Spine - 7 vertebrae. Thoracic Spine - 12 vertebrae. Lumbar Spine - 5 vertebrae. Sacral Spine - 5 fused vertebrae. Coccyx - 3-5 fused vertebrae. A typical vertebra consists of a vertebral body and vertebral arch. These structures enclose the vertebral foramen, in which lies the spinal cord. Seven processes arise from each vertebra. These include two superior articular processes, two inferior articular processes, two transverse processes, and a spinous process. These processes serve as joint facets with adjacent vertebrae, attachment origins for muscles, and form intervertebral foramina from which spinal nerves arise

Postoperative Chest X-rays After Open Reduction Internal Fixation of Clavicle Fractures May Not Be Cost-effective or Necessary

OBJECTIVES: To assess the utility of chest x-rays following open reduction internal fixation of clavicle fractures. Particularly in terms of detection of acute postoperative pneumothorax and cost- effectiveness of obtaining routine chest x-rays post-operatively. DESIGN: A retrospective cohort study. SETTING: Level I trauma centerPatients 236 patients who underwent ORIF from 2013 to 2020 between the ages of 12 and 93. INTERVENTION: Chest x-ray performed post-operatively. MAIN OUTCOME MEASUREMENT: Presence of acute postoperative pneumothorax. RESULTS: Of the 236 patients who underwent surgery 189 (80%) of patients received a CXR post-operatively 7 (3%) of patients experienced respiratory symptoms. All patients who had respiratory symptoms received a post-operative CXR. Those who did not receive a CXR post-operatively did not experience any respiratory complications. Two patients in the cohort had a postoperative pneumothorax, which were both present pre-operatively and unchanged in size post-operatively. Both of these patients were managed with general anesthesia and endotracheal intubation for surgery. The most common finding on CXR post-operatively was atelectasis. The cost of a portable CXR can be upwards of $594 when including technology, personnel fees, and radiological interpretation. CONCLUSION: Post-operative chest x-rays after clavicle open reduction and internal fixation did not detect any acute postoperative pneumothorax in asymptomatic patients. It is not cost-effective to routinely get chest x-rays in patients following open reduction internal fixation of clavicle fractures. In our study, of the 189 chest x-rays performed, only seven patients experienced postoperative respiratory symptoms. Our healthcare system as a total could have saved upwards of$108,108 in total for these patients as they may have been considered non-reimbursable by an insurance provider

Radiographic Predictors of Screw Cutout for Intertrochanteric Fractures Treated With Cephalomedullary Nails

The objective of this study was to determine the predictive value of tip-apex distance (TAD) and Parker\u27s ratio for screw cutout after treatment of intertrochanteric hip fractures with a long cephalomedullary nail. A total of 97 patients with AO/OTA 31-A1-A3 intertrochanteric fractures and a minimum follow-up of 8 weeks were included. Increased Parker\u27s ratio on the anteroposterior radiograph (OR = 1.386, p \u3c .003) and lateral radiograph (OR = 1.138, p \u3c .028) was significantly associated with screw cutout. In a multivariable regression analysis, only the Parker\u27s anteroposterior ratio was significantly associated with risk of screw cutout (OR = 1.393, p = .004), but TAD (OR = 0.977, p = .764) and Parker\u27s lateral ratio (OR 1.032, p = .710) were not independent predictors of cutout. The study concluded that Parker\u27s anteroposterior ratio is the most helpful measurement in predicting screw cutout. (Journal of Surgical Orthopaedic Advances 28(2):115-120, 2019)

Bone Structure and Turnover Status in Postmenopausal Women with Atypical Femur Fracture After Prolonged Bisphosphonate Therapy

Atypical femur fracture (AFF), a serious complication of long-term bisphosphonate therapy, is usually preceded by an incomplete fracture appearing on the lateral femur. AFF is most likely the result of severely suppressed bone turnover (SSBT). However, the differences in bone structure and turnover between patients with incomplete and complete AFF remain unknown. We examined trans-iliac bone biopsies from 12 white postmenopausal women with AFF (incomplete = 5; complete = 7) on BP therapy of \u3e5 years and 43 healthy white premenopausal women. Histomorphometric measurements were performed separately in cancellous, intracortical and endosteal envelopes. Of the 43 histomorphometric measurements on 3 difference bone surfaces (cancellous, intracortical and endosteal), only 2 bone resorption variables (Oc.S/BS and Oc.S/NOS) on the endosteal surface were significantly lower in patients with complete AFF than those with incomplete AFF. Compared to healthy premenopausal women, the trabecular bone volume, thickness and number were all significantly lower in patients with AFF. The dynamic bone formation variables in patients with AFF were significantly reduced on all bone surfaces. The likelihood of a biopsy with no tetracycline labeling was significantly higher in AFF patients than in healthy premenopausal women. Based on these results, we conclude that there are no significant differences in bone turnover between patients with incomplete and complete AFF, suggesting that the suppression of bone turnover had already existed in the femur with incomplete AFF. Compared to healthy premenopausal women, bone turnover is similarly suppressed in patients with either type of AFF

Rate of bone mineral density (BMD) testing and vitamin d nutritional (VDN) status among patients admitted for proximal femur fractures: A retrospective cohort study of a fracture consultative service at a tertiary care medical center

INTRODUCTION: Osteoporotic fractures are a major cause of disability, morbidity, and mortality. A hip fracture is associated with 20% excess mortality in the year following fracture. Approximately 20% of hip fracture patients require long-term nursing home care and only 40% fully regain their prefracture functional level. Despite significant advances in our understanding of the pathogenesis of hip fractures and robust clinical trials demonstrating therapeutic efficacy with an array of drugs, it is unclear how best this knowledge and trial data is translated into patient care. Although much has been reported about the importance of Vitamin D Nutrition (VDN) in preventing hip fractures, the prevalence of vitamin D deficiency or insufficiency among hip fracture patients is largely unknown. A few reports studying this relationship have been published from other countries, but to the best of our knowledge only one such report has been published from the United States. METHODS: The aim of our study is to determine the rate of Bone Mineral Density (BMD) testing and the prevalence of vitamin D deficiency or insufficiency among patients admitted for acute proximal femur fractures over a 5 year period (January 1st, 2011 to December 31st, 2016). The electronic health records of 135 patients with proximal femur fractures were reviewed to determine the rate of BMD testing prior to the fracture and VDN status, as assessed by serum 25-hydroxyvitamin D levels (25-OHD). RESULTS: Of the 135 patients, 91 were women (67%), and 61 were white (45%) with a mean age of 79.2 ± 12.9 y (range 49-98 y). Mean serum 25-OHD was 22.8 ± 12.9 ng/ml (range 4-66 ng/ml), mean serum PTH level was 73.6 ± 58.6 (range 17-430 pg/ml), and mean serum creatinine (Cr) was 1.26 ± 0.94 mg/dl (range 0.16-7.1 mg/dl). The proportions of race and gender, or the mean age, or 25-OHD, or PTH did not change significantly after excluding patients with serum Cr \u3e1.5 mg/dl (n=15) or Cr \u3e2.0 (n=10). Surprisingly, only 35% (n=47) have ever had BMD testing, even though it was approved for screening at-risk population almost a quarter century ago! Unlike the only previous report published in the US, the mean 25-OHD was much higher, but the prevalence of vitamin D deficiency (\u3c20 ng/ml) and insufficiency (\u3c30 ng/ml) was 31% and 54% respectively. Only 15% had optimal VDN. The PTH levels were significantly higher in the entire cohort, and may have contributed to the femur fractures in addition to poor VDN. CONCLUSION: Despite revolutionary advances in our understanding of the pathogenesis of femur fractures, tools to detect it, and effective array of drugs to prevent it, very little impact appears to have occurred in clinical care of the contemporary hip fracture patients. Concerted system based approaches must be incorporated to avoid such preventable and devastating consequences of hip fractures