Literature

Evidence based literature that is truly important to your orthopaedic clinical practice.

A multisite, randomized trial of 250 patients (mean age of 66) with a displaced fracture of the surgical neck of the humerus found that mean Oxford Shoulder Score (OSS) outcomes were essentially the same among those who had surgery (plate fixation or humeral head replacement) and those who were treated with a sling and physical therapy. The OSS measures were made at 6, 12, and 24 months after randomization. Proximal humerus fracture account for an estimated 5% to 6% of adult fractures, with most of them occurring in people older than 65. The authors of this study concluded that, amid what appears to be an uptick in surgical management of such fractures, “these results do not support the trend of increased surgery for patients with displaced fractures of the proximal humerus.

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Pelvic binders can provide lifesaving compression in patients with hemodynamically unstable pelvic injuries. But a report in the March 11, 2015 JBJS Case Connector by Auston et al. emphasizes that such binders may do more harm than good in patients who have acetabular fractures without hemodynamic instability or other pelvic injuries. Because first responders or community physicians often apply pelvic binders, the authors cite the need for clearer guidelines for these devices and updated training of early clinical caregivers regarding their use. Potential complications of binder use cited previously in the literature include pressure sores, damage to internal organs, and sciatic nerve palsy, and Auston et al.

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In December 1996, a group of investigators reported the results of the Fracture Intervention Trial, a randomized controlled trial that compared the effect of alendronate plus calcium or calcium supplementation alone on the risk of fractures in women who already had evidence of vertebral fractures. The results showed that in patients managed with alendronate, there was a 51% decrease in the risk of hip fractures, a 46% decrease in the risk of vertebral fractures, and a 44% decrease in the risk of distal radial fractures when compared with patients managed with calcium alone. These results, as well as those from several other reports, supported the regulatory approval of alendronate (marketed under the trade name Fosamax) for the treatment of postmenopausal osteoporosis in the United States and many countries abroad.

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A level-II retrospective prognostic study of 137 patients with type III open tibia fractures found that those given antibiotics within 66 minutes of sustaining the injury were nearly four times less likely to develop a deep infection during a 90-day follow-up than those receiving antibiotics more than an hour after injury.  This relatively short therapeutic window for antibiotic prophylaxis led study authors to conclude that “prehospital antibiotics may substantially improve outcomes for severe open fractures.” In an interview with Loyola Medicine, study co-author William Lack, MD encouraged further research into the safety and efficacy of allowing paramedics to administer antibiotics in such cases.

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Since our last post about interstate physician licensing in August 2014, 15 states have introduced legislation to approve the plan, which would establish a voluntary process to streamline licensing for physicians in multiple states. Legislative chambers in three of those 15 states—South Dakota, Utah, and Wyoming—have already voted to endorse the compact. According to the Federation of State Medical Boards, the House chambers in Wyoming and Utah passed compact legislation unanimously. It’s not surprising that largely rural states are leading the bandwagon of support for the compact, because one of its main objectives is to increase physician services in underserved areas via face-to-face visits with patients across nearby state borders or via telemedicine.

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Increased security at U.S. airports has increased the probability of orthopaedic implants being detected by metal detectors. A study published in the April 2007 issue of the Journal of Bone and Joint Surgery (JBJS) examined 129 volunteers with a total of 149 implants to determine which devices are most likely to trigger detectors.

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Journal of Trauma-Injury Infection & Critical Care. 61(6):1415-1418, December 2006. Tejwani, Nirmal C. MD; Immerman, Igor MD; Achan, Pramod FRCS; Egol, Kenneth A. MD; McLaurin, Toni MD Abstract: Tourniquet use is effective in producing a bloodless field. It is recommended that the least effective pressures be used to minimize tissue microstructure and biochemical damage from tourniquet application. When applied at the thigh, the minimum effective tourniquet pressure is 90 to 100 mm Hg above systolic BP, and in a normotensive, nonobese patient, pressure of 250 mm Hg is sufficient. Similarly, an arm tourniquet pressure of 200 mm Hg is recommended. The purpose of this survey was to assess the tourniquet pressures used by orthopaedic surgeons, both academic and community based, and their familiarity with associated literature.

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