Standard setting for orthopaedic trauma competencies in postgraduate specialty training- catching those falling behind the curve.

BACKGROUND: The Curriculum for Trauma and Orthopaedics focuses on producing competent Day-One Consultants. However, the expected development trajectory is not clear. It is important, yet difficult to objectively identify trainees who are "falling behind". This project proposes practical, consensus-based thresholds of Operative Trauma Competence at each Waypoint stage of training. METHODS: 32 trainers and 73 trainees in one Deanery were identified. The trainers and trainees were asked their PBA level expectation of a trainee at ST4, ST6 and ST8 for nine trauma competencies. Lower quartile values were calculated providing thresholds. RESULTS: 53 (72%) trainees and 22 (69%) trainers responded. At ST8, the lower quartile threshold was level 4 for all procedures. At ST6, three operation groups became apparent: Group 1 (hip hemiarthroplasty, Dynamic hip screw; k-wire distal radius fracture and Weber C Ankle open reduction, internal fixation (ORIF)) Group 2 (Tibial Nail; Olecranon Tension band wire, ORIF radial shaft; distal radius plate fixation)- Group 3 (supracondylar fracture fixation)Threshold levels for procedures were: Group 1- 4a; Group 2-3b and Group 3- 3a.At ST4, there was more variation and spread in responses, however, expectations could still be similarly grouped: Group 1- 3a; Group 2- 2b and Group 3- 2a. CONCLUSION: In an increasingly competency-based training environment we provide tangible thresholds for expectations of orthopaedic trainees' progression and development. We identified two groups: basic trauma (Group 1 where level 4 competencies should be attained by ST6) and intermediate trauma (Groups 2 and 3 where level 4 competencies should be attained by ST8.).

Planning, conducting, and analyzing a psychophysiological experiment on challenge and threat: A comprehensive tutorial.

The biopsychosocial model of challenge and threat (BPS-CT) is a powerful framework linking psychological processes to reliable patterns of cardiovascular responses during motivated performance situations. Specifically, the BPS-CT poses challenge and threat as two motivational states that can emerge in response to a demanding, self-relevant task, where greater challenge arises when perceived resources are higher than demands, and greater threat arises when perceived resources are lower than demands. By identifying unique patterns of physiological responses associated with challenge and threat, respectively, the BPS-CT affords insight into subjective appraisals of resources and demands, and their determinants, during motivated performance situations. Despite its broad utility, lack of familiarity with physiological concepts and difficulty with identifying clear guidelines in the literature are barriers to wider uptake of this approach by behavioral researchers. Our goal is to remove these barriers by providing a comprehensive, step-by-step tutorial on conducting an experiment using the challenge and threat model, offering concrete recommendations for those who are new to the method, and serving as a centralized collection of resources for those looking to deepen their understanding. The tutorial spans five parts, covering theoretical introduction, lab setup, data collection, data analysis, and appendices offering additional details about data analysis and equipment. With this, we aim to make challenge and threat research, and the insights it offers, more accessible to researchers throughout the behavioral sciences.

Spectral slowing in chronic stroke reflects abnormalities in both periodic and aperiodic neural dynamics.

Decades of electrophysiological work have demonstrated the presence of "spectral slowing" in stroke patients - a prominent shift in the power spectrum towards lower frequencies, most evident in the vicinity of the lesion itself. Despite the reliability of this slowing as a marker of dysfunctional tissue across patient groups as well as animal models, it has yet to be explained in terms of the pathophysiological processes of stroke. To do so requires clear understanding of the neural dynamics that these differences represent, acknowledging the often overlooked fact that spectral power reflects more than just the amplitude of neural oscillations. To accomplish this, we used a combination of frequency domain and time domain measures to disambiguate and quantify periodic (oscillatory) and aperiodic (non-oscillatory) neural dynamics in resting state magnetoencephalography (MEG) recordings from chronic stroke patients. We found that abnormally elevated low frequency power in these patients was best explained by a steepening of the aperiodic component of the power spectrum, rather than an enhancement of low frequency oscillations, as is often assumed. However, genuine oscillatory activity at higher frequencies was also found to be abnormal, with patients showing alpha slowing and diminished oscillatory activity in the beta band. These aperiodic and periodic abnormalities were found to covary, and could be detected even in the un-lesioned hemisphere, however they were most prominent in perilesional tissue, where their magnitude was predictive of cognitive impairment. This work redefines spectral slowing as a pattern of changes involving both aperiodic and periodic neural dynamics and narrows the gap in understanding between non-invasive markers of dysfunctional tissue and disease processes responsible for altered neural dynamics.

Individual Differences in Multisensory Processing Are Related to Broad Differences in the Balance of Local versus Distributed Information.

The brain's ability to extract information from multiple sensory channels is crucial to perception and effective engagement with the environment, but the individual differences observed in multisensory processing lack mechanistic explanation. We hypothesized that, from the perspective of information theory, individuals with more effective multisensory processing will exhibit a higher degree of shared information among distributed neural populations while engaged in a multisensory task, representing more effective coordination of information among regions. To investigate this, healthy young adults completed an audiovisual simultaneity judgment task to measure their temporal binding window (TBW), which quantifies the ability to distinguish fine discrepancies in timing between auditory and visual stimuli. EEG was then recorded during a second run of the simultaneity judgment task, and partial least squares was used to relate individual differences in the TBW width to source-localized EEG measures of local entropy and mutual information, indexing local and distributed processing of information, respectively. The narrowness of the TBW, reflecting more effective multisensory processing, was related to a broad pattern of higher mutual information and lower local entropy at multiple timescales. Furthermore, a small group of temporal and frontal cortical regions, including those previously implicated in multisensory integration and response selection, respectively, played a prominent role in this pattern. Overall, these findings suggest that individual differences in multisensory processing are related to widespread individual differences in the balance of distributed versus local information processing among a large subset of brain regions, with more distributed information being associated with more effective multisensory processing. The balance of distributed versus local information processing may therefore be a useful measure for exploring individual differences in multisensory processing, its relationship to higher cognitive traits, and its disruption in neurodevelopmental disorders and clinical conditions.

A Novel Method of Treatment for a Mal-United Galeazzi Fracture With Dislocation of the Distal Radioulnar Joint Using Scarf Osteotomy.

The Galeazzi fracture is an unstable fracture-dislocation of the forearm. There have been reports of non-union of the radius despite rigid internal fixation with a plate. We present the case of a 25-year-old male who fell from his bicycle, sustaining a closed Galeazzi fracture-dislocation. Definitive surgical fixation involved internal fixation using a six-hole dynamic compression plate. Post-operatively, the patient noted a significant reduction in pronation. The fracture had united but with approximately 5 mm of radial shortening. The operating consultant formulated a surgical plan to resolve the complex nature of this mal-united Galeazzi fracture. A scarf-type osteotomy would correct the deformity and reduce the risk of non-union. Clinically and radiographically, the scarf osteotomy had healed by three months. The patient was very pleased that he underwent revision surgery, as the pain from the wrist resolved and the range of movement improved.

Extradigital glomangiomyoma of the forearm mimicking peripheral nerve sheath tumour and thrombosed varicose vein.

Extradigital glomus tumour is uncommon, little-known outside of its subungual location, and may present without its classic triad of tenderness, cold sensitivity and paroxysmal pain. Imaging is non-specific and diagnosis is often delayed, sometimes for years, leading to unnecessary morbidity. Surgical excision is the treatment of choice, although technique depends on case specifics. Histological subtypes depend on the relative prominence of glomus cells, vascular structures and smooth muscle. The vast majority of glomus tumours are benign. We highlight the importance of considering extradigital glomus tumours when generating differential diagnoses of an atypical painful lesion in a variety of clinical specialties.

Simultaneous 4 Compartment Pressure Monitoring in Diagnosis of Chronic Exertional Compartment Syndrome of the Forearm.

The authors describe a technique for bilateral simultaneous measuring of forearm compartments pressure for assessment of suspected chronic exertional compartment syndrome of the forearm. Under ultrasound guidance, 18-G cannulae were inserted bilaterally into the superficial flexor and dorsal extensor forearm compartments. The imaging was used to confirm safe subfascial placement, and ensured no kinking or catching on the muscle bellies during dynamic movements. An arterial pressure transducer with 4 portals allowed simultaneous measurements from 4 compartments. Intracompartmental pressure (ICP) was measured in 2 ways, (1) hand in a relaxed position and (2) power grip with Jamar Dynamometer. After baseline measurements were taken, the patient undertook a period of rowing sufficient to generate symptoms. ICPs were then recorded at 1, 2, and 5 minutes by which time symptoms had resolved. Using this method ICPs in 4 myofascial compartments was measured in the same limb, simultaneously, pre- and postexercise.

Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial.

BACKGROUND: Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. The use of immediate surgical fixation to manage this type of fracture has increased, despite insufficient evidence of improved outcomes over non-surgical management. The SWIFFT trial compared the clinical effectiveness of surgical fixation with cast immobilisation and early fixation of fractures that fail to unite in adults with scaphoid waist fractures displaced by 2 mm or less. METHODS: This pragmatic, parallel-group, multicentre, open-label, two-arm, randomised superiority trial included adults (aged 16 years or older) who presented to orthopaedic departments of 31 hospitals in England and Wales with a clear bicortical fracture of the scaphoid waist on radiographs. An independent remote randomisation service used a computer-generated allocation sequence with randomly varying block sizes to randomly assign participants (1:1) to receive either early surgical fixation (surgery group) or below-elbow cast immobilisation followed by immediate fixation if non-union of the fracture was confirmed (cast immobilisation group). Randomisation was stratified by whether or not there was displacement of either a step or a gap of 1-2 mm inclusive on any radiographic view. The primary outcome was the total patient-rated wrist evaluation (PRWE) score at 52 weeks after randomisation, and it was analysed on an available case intention-to-treat basis. This trial is registered with the ISRCTN registry, ISRCTN67901257, and is no longer recruiting, but long-term follow-up is ongoing. FINDINGS: Between July 23, 2013, and July 26, 2016, 439 (42%) of 1047 assessed patients (mean age 33 years; 363 [83%] men) were randomly assigned to the surgery group (n=219) or to the cast immobilisation group (n=220). Of these, 408 (93%) participants were included in the primary analysis (203 participants in the surgery group and 205 participants in the cast immobilisation group). 16 participants in the surgery group and 15 participants in the cast immobilisation group were excluded because of either withdrawal, no response, or no follow-up data at 6, 12, 26, or 52 weeks. There was no significant difference in mean PRWE scores at 52 weeks between the surgery group (adjusted mean 11·9 [95% CI 9·2-14·5]) and the cast immobilisation group (14·0 [11·3 to 16·6]; adjusted mean difference -2·1 [95% CI -5·8 to 1·6], p=0·27). More participants in the surgery group (31 [14%] of 219 participants) had a potentially serious complication from surgery than in the cast immobilisation group (three [1%] of 220 participants), but fewer participants in the surgery group (five [2%]) had cast-related complications than in the cast immobilisation group (40 [18%]). The number of participants who had a medical complication was similar between the two groups (four [2%] in the surgery group and five [2%] in the cast immobilisation group). INTERPRETATION: Adult patients with scaphoid waist fractures displaced by 2 mm or less should have initial cast immobilisation, and any suspected non-unions should be confirmed and immediately fixed with surgery. This treatment strategy will help to avoid the risks of surgery and mostly limit the use of surgery to fixing fractures that fail to unite. FUNDING: National Institute for Health Research Health Technology Assessment Programme.

Effect of Alendronic Acid on Fracture Healing: A Multicenter Randomized Placebo-Controlled Trial.

There is a concern that bisphosphonates may impair fracture healing because of their inhibitory effects on bone turnover. Here we evaluated the effects of early bisphosphonate therapy on fracture healing and functional outcome following a fracture of the distal radius. The fracture and bisphosphonates (FAB) trial was a double-blind, randomized, placebo-controlled trial involving 15 trauma centers in the United Kingdom. We enrolled 421 bisphosphonate-naive patients aged ≥50 years with a radiographically confirmed fracture of the distal radius and randomized them in a 1:1 ratio to receive alendronic acid 70 mg once weekly (n = 215) or placebo (n = 206) within 14 days of the fracture. The primary outcome measure was the proportion of fractures that had radiologically united at 4 weeks as assessed by an observer, blinded to treatment allocation. Secondary outcomes included the Disabilities of the Arm Shoulder and Hand (DASH) questionnaire, range of wrist movement and grip strength, pain and analgesia requirements, and the rate of malunion. The mean ± SD age of participants was 63 ± 8.5 years and 362 (86%) were female. At 4 weeks, 48 of 202 (23.8%) fractures had united in the alendronic acid group compared with 52 of 187 (27.8%) in the placebo group (observed absolute proportion difference 4.0%; 95% CI, -4.7% to 12.8%; p = 0.36). The absolute proportion difference between groups based on imputed data was 4.5% (95% CI, -4.7% to 13.8%; p = 0.30). There was no significant difference in the proportion of fractures that had united at any other time point and no differences in the DASH score, pain at the fracture site, grip strength, or any other clinical outcome. We conclude that among patients aged 50 years and above with a distal radius fracture, early administration of alendronic acid does not adversely affect fracture union or clinical outcome. These findings suggest bisphosphonate therapy can be safely commenced early after fracture if clinically indicated. © 2019 American Society for Bone and Mineral Research.

Segmental fracture of the scaphoid.

We present a rare case of segmental fracture of the scaphoid. This case highlights the importance of using appropriate imaging modalities to assess the presence and morphology of fractures.

Management of a 15-year-old scaphoid non-union.

Scaphoid non-union affects wrist joint function and is often associated with a predictable pattern of degenerative change. A 30-year-old man presented with a symptomatic 15-year-old right scaphoid fracture with secondary scaphoid non-union advanced collapse of his right wrist. There was no evidence of avascular necrosis. The initial injury was from a fall onto his outstretched hand. We performed a right scaphoid open reduction, internal fixation and iliac crest bone graft. One year after the operation, the patient had good wrist function and grip strength. A CT scan showed union of the fracture. Studies have shown that if the time between initial fracture and treatment of non-union exceeds 5 years, the chances of healing of the non-union are markedly reduced. In our case, despite the long duration between timing of injury and surgery, there was union and good return of function.

Radius and Ulna Stress Fractures in a Patient with Neuromyelitis Optica: A Case Report.

INTRODUCTION: Stress fractures are more common in the weight-bearing bones of the lower limb and are particularly prevalent in athletes. Whereas, those of the upper limb are usually reported as unique events in rare circumstances. CASE REPORT: We present a case of a 40-year-old White British female with neuromyelitis optica (NMO) who mobilized in a wheelchair and presented to our center in April 2016 with a week-long history of a hot, swollen, and unstable right forearm. Plain radiographs demonstrated fractures of both the radius and ulna of the dominant right arm. These were managed by open reduction and internal fixation to facilitate mobility and transfer using the forearm. Intra-operatively, these were confirmed to be fatigue fractures, and there was evidence that the fracture was several days old. The neurological deficit in this patient had led to a delayed presentation owing to the lack of pain. Unfortunately, this construct failed within 8days, and a refixation was performed 2months later. 1year following the revision, no further problems have been reported, and there has been satisfactory union. CONCLUSION: This is the first report in the published literature of a stress fracture in a patient with NMO. We recommend screening for stress fractures with a nuclear bone scan in patients who mobilize in atypical ways, particularly if their sensation is compromised. The use of constructs stronger than those routinely applied to the upper limb should also be considered if patients are weight bearing through their arms.

Multivariate pattern analysis of event-related potentials predicts the subjective relevance of everyday objects.

Potentially decision-relevant stimuli have been proposed to undergo immediate semantic processing. The current study investigated whether information regarding the general desirability ('Wanting') of visually presented 'everyday' objects was rapidly and automatically processed. Participants completed a foreground task while their electroencephalogram (EEG) was recorded, and task-irrelevant images were presented in the background. Following this, participants rated the images with regards to Wanting and the potentially related attributes of Relevance, Familiarity, Aesthetic Pleasantness and Time Reference. Multivariate pattern classification was used to predict the ratings from patterns of EEG data. Prediction of Wanting and Relevance was possible between 100 and 150ms following stimulus presentation. The other dimensions could not be predicted. Wanting and Relevance ratings were highly correlated and displayed similar feature weight maps. The current results suggest that the general desirability and subjective relevance of everyday objects is rapidly and automatically processed for a wide range of visual stimuli.

Development of a patient-centered bilingual prescription drug label.

Research shows that prescription drug labels are often difficult for patients to understand, which contributes to medication errors and nonadherence. In this study, the authors developed and qualitatively evaluated an evidence-based bilingual prescription container label designed to improve understanding. The authors developed several prototypes in English only or in English and Spanish. The labels included an image of the drug, an icon to show its purpose, and plain-language instructions presented in a 4-time-of-day table. In 5 focus groups and interviews that included 57 participants, patients and pharmacists critically reviewed the designs and compared them with traditional medication labels and reformatted labels without illustrations. Patients strongly preferred labels that grouped patient-relevant content, highlighted key information, and included drug indication icons. They also preferred having the 4-time-of-day table and plain-language text instructions as opposed to either one alone. Patients preferred having pertinent warnings on the main label instead of auxiliary labels. Pharmacists and Latino patients valued having Spanish and English instructions on the label, so both parties could understand the content. The final label design adheres to the latest national- and state-level recommendations for label format and incorporates additional improvements on the basis of patient and pharmacist input. This design may serve as a prototype for improving prescription drug labeling.

MMP-14 and MMP-2 are key metalloproteases in Dupuytren's disease fibroblast-mediated contraction.

Dupuytren's disease (DD) is a common fibrotic condition of the palmar fascia, leading to deposition of collagen-rich cords and progressive flexion of the fingers. The molecular mechanisms underlying the disease are poorly understood. We have previously shown altered expression of extracellular matrix-degrading proteases (matrix metalloproteases, MMPs, and 'a disintegrin and metalloprotease domain with thrombospondin motifs', ADAMTS, proteases) in palmar fascia from DD patients compared to control and shown that the expression of a sub-set of these genes correlates with post-operative outcome. In the current study we used an in vitro model of collagen contraction to identify the specific proteases which mediate this effect. We measured the expression of all MMPs, ADAMTSs and their inhibitors in fibroblasts derived from the palmar fascia of DD patients, both in monolayer culture and in the fibroblast-populated collagen lattice (FPCL) model of cell-mediated contraction. Key proteases, previously identified in our tissue studies, were expressed in vitro and regulated by tension in the FPCL, including MMP1, 2, 3, 13 and 14. Knockdown of MMP2 and MMP14 (but not MMP1, 3 and 13) inhibited cell-mediated contraction, and knockdown of MMP14 inhibited proMMP-2 activation. Interestingly, whilst collagen is degraded during the FPCL assay, this is not altered upon knockdown of any of the proteases examined. We conclude that MMP-14 (via its ability to activate proMMP-2) and MMP-2 are key proteases in collagen contraction mediated by fibroblasts in DD patients. These proteases may be drug targets or act as biomarkers for disease progression.

Metalloproteinase gene expression correlates with clinical outcome in Dupuytren's disease.

PURPOSE: We have previously demonstrated that gene expression levels of matrix metalloproteinases (MMPs), related metalloproteinases "a disintegrin and metalloproteinase with thrombospontin motifs" (ADAMTSs), and tissue inhibitors of metalloproteinases (TIMPs) differed when comparing palmar fascia from 19 patients with Dupuytren's disease (DD) with 19 disease-free controls. We undertook to investigate whether the extent of this altered gene expression was related to clinical outcome. METHODS: All the patients with DD were followed up for an average of 14 months from their primary fasciectomy. Clinical outcome was scored by measuring range of motion to assess total extension deficit (fixed flexion deformity [FFD] of the affected digit), total further flexion, and grip strength, and using 3 validated outcome scores: the Disability of Arm, Shoulder and Hand (DASH) questionnaire, the Michigan Hand Questionnaire (MHQ), and the Vancouver Scar Scale (VSS). RESULTS: We found a considerable correlation between levels of gene expression of several of the MMPs (MMP2, MMP13, MMP14, MMP16, MMP 19) and ADAMTSs (ADAMTS2, ADAMTS4, ADAMTS5, ADAMTS14, ADAMTS16) and the recurrence of FFD over the follow-up period. The expression of all these genes had been shown to be increased in DD samples compared with controls. We also found that the expression levels of several of these genes correlated with 2 other preoperative measurements, total further flexion (digital roll-up) and grip strength. CONCLUSIONS: These findings suggest that gene expression levels of key MMPs and ADAMTSs could be used to predict 1-year clinical outcome in terms of recurrent FFD of the affected finger following fasciectomy for DD. This implies that knowledge of these expression levels could be used to direct appropriate surgical and adjuvant intervention for DD. This study also provides further evidence to support the functional link between metalloproteinase gene expression and symptomatic progression or recurrence. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Outcome of traumatic subtrochanteric femoral fractures fixed using cephalo-medullary nails.

We performed a retrospective review of 101 patients sustaining 102 traumatic, non-pathological subtrochanteric fractures treated with cephalo-medullary nailing over a period of 6 years from 1999 to 2005. Mean follow up was 24 weeks (range: 6-96). Twenty patients were lost to follow up and 21 died, whilst 57 of 60 fractures were followed to union. There were 19 fractures fixed in varus, as defined as a varus angulation of greater than 10 degrees at the fracture site. Implant failure, 9 of the 10 malunions and all 3 of the non-unions occurred in the varus group whilst only 1 malunion occurred in the satisfactory reduction group. This difference in outcome is statistically significant (p<0.0001). Twenty four of the 60 patients had undergone open reduction at the time of fixation. There were three malunions and one non-union in the open reduction group compared with six and two, respectively in the closed group (p>0.05). Post-operative recovery rates, infection rates and other complications were similar for both groups. We therefore advocate the use of open reduction where necessary to avoid varus malreduction to avoid such complications, particularly as open reduction was not associated with a higher complication rate in this series. The study supports the use of cephalo-medullary nailing for subtrochanteric fractures with a union rate of 95%.

A complete expression profile of matrix-degrading metalloproteinases in Dupuytren's disease.

PURPOSE: Dupuytren's disease (DD) is a common fibrotic condition of the palmar fascia, leading to deposition of collagen-rich cords and finger contractions. The metzincin superfamily contains key enzymes in the turnover of collagen and other extracellular matrix macromolecules. A number of broad-spectrum matrix metalloproteinase inhibitors, used in cancer clinical trials, caused side effects of DD-like contractures. We tested the hypothesis that changes in the expression of specific metalloproteinases underlie or contribute to the fibrosis and contracture seen in DD. METHODS: We collected tissue from patients with DD and used normal palmar fascia as a control. We profiled the expression of the entire matrix metalloproteinase (MMP), tissue inhibitor of metalloproteinases (TIMP), and a disintegrin and metalloproteinase domain with thrombospondin motif (ADAMTS) gene families in these tissues using real-time reverse-transcription polymerase chain reaction. RESULTS: A number of metalloproteinases and inhibitors are regulated in DD. The expression of 3 key collagenases, MMP1, MMP13, and MMP14 is increased significantly in the DD nodule, as is the expression of the collagen biosynthetic enzyme ADAMTS14. The expression of MMP7, an enzyme with broad substrate specificity, is increased in the DD nodule and remains equally expressed in the DD cord. TIMP1 expression is increased significantly in DD nodule compared with normal palmar fascia. CONCLUSIONS: This study measured the expression of all MMP, ADAMTS, and TIMP genes in DD. Contraction and fibrosis may result from: (1) increased collagen biosynthesis mediated by increased ADAMTS-14; (2) an increased level of TIMP-1 blocking MMP-1- and MMP-13-mediated collagenolysis; and (3) contraction enabled by MMP-14-mediated pericellular collagenolysis (and potentially MMP-7), which may escape inhibition by TIMP-1. The complete expression profile will provide a knowledge-based approach to novel therapeutics targeting these genes.