Dynamic evolution of locomotor performance independent of changes in extended phenotype use in spiders.

Many animals use self-built structures (extended phenotypes) to enhance body functions, such as thermoregulation, prey capture or defence. Yet, it is unclear whether the evolution of animal constructions supplements or substitutes body functions-with disparate feedbacks on trait evolution. Here, using brown spiders (Araneae: marronoid clade), we explored if the evolutionary loss and gain of silken webs as extended prey capture devices correlates with alterations in traits known to play an important role in predatory strikes-locomotor performance (sprint speed) and leg spination (expression of capture spines on front legs). We found that in this group high locomotor performance, with running speeds of over 100 body lengths per second, evolved repeatedly-both in web-building and cursorial spiders. There was no correlation with running speed, and leg spination only poorly correlated, relative to the use of extended phenotypes, indicating that web use does not reduce selective pressures on body functions involved in prey capture and defence per se. Consequently, extended prey capture devices serve as supplements rather than substitutions to body traits and may only be beneficial in conjunction with certain life-history traits, possibly explaining the rare evolution and repeated loss of trapping strategies in predatory animals.

What Is the Safe Window from Definitive Fixation to Flap Coverage in Type 3B Open Tibia Fractures? Supporting Plastics and Orthopaedics Alliance in Reducing Trauma Adverse Events (SPARTA).

OBJECTIVES: To delineate whether a "safe" window exists for timing from definitive fixation to definitive soft tissue coverage in the treatment of open tibial diaphyseal fractures requiring flap coverage. DESIGN: International multicenter, retrospective comparative cohort study. PATIENTS/PARTICIPANTS: Three hundred and seventy-three (n = 373) patients who sustained an open tibial shaft fracture requiring flap coverage. METHODS: We evaluated the deep infection rates based on the timing between the definitive fixation and flap coverage. We determined several intervals of time from the day of definitive fixation (regardless of time from injury) and flap coverage. If performed on the same operative setting these were considered day 0. We evaluated coverage after 2 and 5 days from definitive fixation based on time versus infection rate curve inflection points. We adjusted for time to debridement and antibiotics within an hour. MAIN OUTCOME MEASUREMENT: Deep infection after definitive fixation and flap coverage. RESULTS: The mean age of the cohort was 42.4 years (SD = 18.2) and 270 were male (72.4%). The deep infection rate after flap coverage was 20.6% (77/373). Definitive fixation to flap coverage time of up to 2 days was not associated with an increased risk of infection [relative risk (RR) = 1.12; 95% confidence interval, 0.92-1.37; P = 0.26]. There was an increased risk of deep infection for more than 2 days (RR = 1.59) and >5 days (RR = 1.64). CONCLUSION: This study observed a "safe" window of up to 2 days between definitive fixation and flap coverage in open tibial shaft fractures requiring coverage before a statistical increase in risk of deep infection rate occurred. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Current Perspectives on the Management of Bone Fragments in Open Tibial Fractures: New Developments and Future Directions.

Open tibial fractures may be associated with bone loss at the time of the injury or following surgical debridement of the fracture. This article discusses the various treatment options available and the latest developments surrounding the management of free bone fragments in open tibial fractures.

Orthoplastic Reconstruction of Type IIIB Open Tibial Shaft Fractures Using Debrided, Devitalized Cortical Segments: Health-Related Quality-of-Life Outcomes.

OBJECTIVE: To determine health-related quality of life (HRQoL) in patients who sustained type IIIB open tibial diaphyseal (OTA/AO-42) fractures and underwent orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) versus those who did not require the use of devitalized bone as part of their orthoplastic reconstruction. DESIGN: Consecutive cohort study. PATIENTS/PARTICIPANTS: The study included 74 patients who sustained a type IIIB open tibial diaphyseal fracture requiring orthoplastic reconstruction over a 4-year period in a major trauma center. All patients underwent a two-stage orthoplastic reconstruction protocol, with the second stage consisting of definitive fixation and flap coverage (free fascial anterolateral thigh flap) in a single sitting. Patients were contacted at a minimum of 30 months to measure HRQoL. INTERVENTION: Patients requiring ORDB versus those who did not require the use of devitalized bone as part of their orthoplastic reconstruction. MAIN OUTCOME MEASUREMENTS: The primary outcome measure was HRQoL ascertained using Euro-Qol (EQ)-5D and Short-Form (SF)-36 scores. RESULTS: Thirty (n = 30) patients underwent ORDB with the remaining 44 not requiring devitalized bone as part of their reconstruction. The median age was 46.5 years [interquartile range (IQR) 29.0], with a median follow-up of 3.8 years (IQR 1.5). The median cohort EQ-5D was 0.743 (IQR 0.222), ORDB 0.743 (IQR 0.195) versus non-ORDB 0.748 (IQR 0.285), P = 0.71. The median physical component SF-36 score was 80 (IQR 50), ORDB 80 (IQR 34.5) versus non-ORDB 77.5 (IQR 58.75), P = 0.72. The median mental component SF-36 score was 80 (IQR 28), ORDB 80 (IQR 21) versus non-ORDB 80 (IQR 36), P = 0.29. CONCLUSIONS: In patients who sustained a type IIIB open tibial shaft fracture and who underwent a 2-stage orthoplastic reconstruction, ORDB does not seem to be associated with inferior health-related quality of life based on EQ-5D or SF-36 scores. The results of this approach should be considered within the strict combined orthoplastic approach in the study unit. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Stabilized Morphological Evolution of Spiders Despite Mosaic Changes in Foraging Ecology.

A prominent question in animal research is how the evolution of morphology and ecology interacts in the generation of phenotypic diversity. Spiders are some of the most abundant arthropod predators in terrestrial ecosystems and exhibit a diversity of foraging styles. It remains unclear how spider body size and proportions relate to foraging style, and if the use of webs as prey capture devices correlates with changes in body characteristics. Here, we present the most extensive data set to date of morphometric and ecological traits in spiders. We used this data set to estimate the change in spider body sizes and shapes over deep time and to test if and how spider phenotypes are correlated with their behavioral ecology. We found that phylogenetic variation of most traits best fitted an Ornstein-Uhlenbeck model, which is a model of stabilizing selection. A prominent exception was body length, whose evolutionary dynamics were best explained with a Brownian Motion (free trait diffusion) model. This was most expressed in the araneoid clade (ecribellate orb-weaving spiders and allies) that showed bimodal trends toward either miniaturization or gigantism. Only few traits differed significantly between ecological guilds, most prominently leg length and thickness, and although a multivariate framework found general differences in traits among ecological guilds, it was not possible to unequivocally associate a set of morphometric traits with the relative ecological mode. Long, thin legs have often evolved with aerial webs and a hanging (suspended) locomotion style, but this trend is not general. Eye size and fang length did not differ between ecological guilds, rejecting the hypothesis that webs reduce the need for visual cue recognition and prey immobilization. For the inference of the ecology of species with unknown behaviors, we propose not to use morphometric traits, but rather consult (micro-)morphological characters, such as the presence of certain podal structures. These results suggest that, in contrast to insects, the evolution of body proportions in spiders is unusually stabilized and ecological adaptations are dominantly realized by behavioral traits and extended phenotypes in this group of predators. This work demonstrates the power of combining recent advances in phylogenomics with trait-based approaches to better understand global functional diversity patterns through space and time. [Animal architecture; Arachnida; Araneae; extended phenotype; functional traits; macroevolution; stabilizing selection.].

Definitive Fixation Outcomes of Open Tibial Shaft Fractures: Systematic Review and Network Meta-analysis.

OBJECTIVES: To delineate if there were differences in outcomes between definitive fixation strategies in open tibial shaft fractures. DATA SOURCES: MEDLINE, EMBASE, CENTRAL, and OpenGrey. STUDY SELECTION: Randomized and Quasi-randomized studies analyzing adult patients (>18 years) with open tibial shaft fractures (AO-42), undergoing definitive fixation treatment of any type. DATA EXTRACTION: Data regarding patient demographics, definitive bony/soft-tissue management, irrigation, type of antibiotics, and follow-up. Definitive intervention choices included unreamed intramedullary nailing (UN), reamed intramedullary nailing, plate fixation, multiplanar, and uniplanar external fixation (EF). The primary outcome was unplanned reoperation rate. Cochrane risk of bias tool and Grading of Recommendation Assessment, Development and Evaluation systems were used for quality analysis. DATA SYNTHESIS: A random-effects meta-analysis of head-to-head evidence, followed by a network analysis that modeled direct and indirect data was conducted to provide precise estimates [relative risk (RR) and associated 95% confidence interval (95% CI)]. RESULTS: In open tibial shaft fractures, direct comparison UN showed a lower risk of unplanned reoperation versus EF (RR 0.67, 95% CI 0.43-1.05, P = 0.08, moderate confidence). In Gustilo type III open fractures, the risk reduction with nailing compared with EF was larger (RR 0.61, 95% CI 0.37-1.01, P = 0.05, moderate confidence). UN had a lower reoperation risk compared with reamed intramedullary nailing (RR 0.91, 95% CI 0.58-1.4, P = 0.68, low confidence); however, this was not significant and did not demonstrate a clear advantage. CONCLUSIONS: Intramedullary nailing reduces the risk of unplanned reoperation by a third compared with EF, with a slightly larger reduction in type III open fractures. Future trials should focus on major complication rates and health-related quality of life in high-grade tibial shaft fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Acute Compartment Syndrome in Type IIIB Open Tibial Shaft Fractures Using a 2-Stage Orthoplastic Approach.

OBJECTIVE: To determine the rate of acute compartment syndrome (ACS) in a series of patients with Gustilo-Anderson type IIIB open tibial shaft fractures that were treated using a specific 2-stage orthoplastic protocol. DESIGN: Consecutive cohort study. PATIENTS/PARTICIPANTS: Ninety-three (n = 93) consecutive patients with a type IIIB open tibial shaft fracture (OTA/AO-42) treated using a 2-stage orthoplastic approach, between August 2015 and January 2018. After exclusions, 83 (n = 83) were eligible for analysis. INTERVENTION: Colloid resuscitation and 2-stage orthoplastic reconstruction of type IIIB open tibial shaft fracture. Stage 1 consists of "3-vessel view" early debridement and temporary internal fixation, with stage 2 consisting of a single-stage fix and flap. MAIN OUTCOME MEASUREMENTS: Rate of ACS. Secondary outcomes included early/late sequelae of missed ACS, deep infection, arterial injury, nonunion, and flap failure. RESULTS: Eighty-three (n = 83) patients were included for analysis. The median age was 45.4 years [interquartile range (IQR) 35] with a median follow-up of 1.6 years (IQR 0.8). The median number of operations was 2.0 (IQR 4). For the primary outcome, there were a total of 0 (0/83) patients who required fasciotomy or developed early/late clinical sequelae of missed ACS. Six (6/83, 7.2%) patients developed deep infection, 18 patients (18/83, 21.7%) experienced nonischemic arterial injury, 5 patients (5/83, 6.0%) experienced nonunion, with 4 patients (4/83, 4.8%) experiencing flap failure. Diabetes was the only variable associated with deep infection (P = 0.025) and nonunion (P < 0.001). CONCLUSIONS: Patients with type IIIB open tibial shaft fractures treated with colloid resuscitation and a 2-stage orthoplastic protocol, which includes early "3-vessel view" exposure and debridement, do not appear to develop ACS. Furthermore, no sequelae of missed compartment syndrome was observed at final follow-up. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Type III open complete articular fractures of the distal humerus: case series outcomes after orthoplastic reconstruction.

Background: Open complete articular injuries of this distal humerus are rare injuries which are challenging to manage. The study unit aims to present a small case series of Gustilo-Anderson type III open complete articular fractures which have undergone a single-stage definitive fixation and soft-tissue coverage, presenting their functional outcomes. Methods: Retrospective case series identifying all type IIIB AO 13-C3 distal humeral fractures from the unit trauma database. The primary outcome was the Oxford Elbow Score. Secondary outcomes included deep infection, nonunion, and reoperation. Results: A total of six patients were identified, (four open type IIIA, 2 type IIIB). All patients underwent single-sitting definitive fixation and soft-tissue coverage. Mean range of motion arc was 90 degrees. The median Oxford Elbow Score was 35 (range 21-43), representative of mild to moderate arthritis. One patient (n = 1) developed deep infection at 24 months and required reoperation. All patients (n = 6) proceeded to union at the latest follow-up. We present a case report of a 59-years-old patient who sustained a type IIIB, AO 13-C3 distal humeral fracture who underwent single-sitting definitive fixation and flap coverage. Conclusion: This case series reports that positive functional outcomes representative of mild/moderate arthritis at short to midterm follow-up can be achieved after definitive fixation and soft-tissue coverage in a single sitting, including when the soft tissue is deficient. This is a rare injury which is under-reported in the literature.

Caffeine-Induced Psychosis and a Review of Statutory Approaches to Involuntary Intoxication.

Caffeine is the most commonly ingested psychoactive substance in the world. Although caffeine-use disorder is not recognized as a formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, five disorders related to caffeine use are enumerated therein. An evolving literature suggests that caffeine is one of many licit substances that may cause psychotic symptoms in higher doses. Here, we present a case in which a defendant ingested large quantities of caffeine, which result in transient psychosis and a successful affirmative defense of involuntary intoxication. The purpose of this article is to summarize states' statutory approaches to involuntary intoxication, given that the term is defined variably, if defined at all. Evaluators must be careful to apply jurisdictionally appropriate standards in involuntary intoxication defenses because the bar for this total defense differs across localities.

Resuscitation in hip fractures: The practicality and clinical effectiveness of pre-operative resuscitation of patients with hip fracture using blood products.

INTRODUCTION: This study aimed to determine the practicality and estimate the effect of administering pre-operative blood product resuscitation to a consecutive, prospectively recruited cohort of 100 patients admitted to a single centre with a hip fracture with all other treatment unchanged. METHOD: 100 patients aged 65 years or over admitted acutely to our unit with unilateral fractured femoral neck during the study period were included in this study, regardless of cognitive function. Patients were excluded only if there were relevant medical comorbidities or consent was declined. Each patient was resuscitated with a single unit of packed red cells in the immediate perioperative period in addition to standard care. The primary outcome was to establish the feasibility of the study protocol employed in using blood products to resuscitate eligible patients and recording reasons for any failures to include eligible patients. Additional data regarding mortality at 30 days following injury, subsequent blood product use, any transfusion related adverse reactions and total blood product use was measured. RESULTS: We were able to show that it is safe and practicable to deliver blood as an early resuscitative strategy in the frail elderly hip fracture population. The mortality rate of the study cohort was 3%. No adverse reaction was observed in any of the 99 patients given blood as a result of the resuscitation strategy and no morbidity was seen that could be attributed to the effect of giving blood. The total amount of blood received by comparable cohorts in the study period and the two preceding years were similar. CONCLUSIONS: The study suggests that in the hip fracture population it is both practical and beneficial to move away from reactive transfusion regimens, and instead centre efforts instead on optimal resuscitation at the initial presentation.

Plate-Assisted Intramedullary Nailing of Gustilo Type IIIB Open Tibial Diaphyseal Fractures: Does Adjunctive Plate Retention Affect Complication Rate?

OBJECTIVES: To investigate the complication rates after use of retained adjunctive plate (RAP) fixation with intramedullary nailing of Gustilo-Anderson type IIIB open tibia fractures, as part of a 2-stage orthoplastic approach. DESIGN: Consecutive cohort study. PATIENTS/PARTICIPANTS: One hundred and thirty-seven consecutive patients with a Gustilo-Anderson type IIIB open diaphyseal tibia fracture (OTA/AO 42) treated between May 2014 and January 2018. Ninety-eight patients (RAP = 67; non-RAP = 31) met the inclusion criteria and underwent 2-stage reconstruction. All patients were treated using a small fragment adjunctive plate to hold the fracture reduced before intramedullary nailing. INTERVENTION: At stage 2, the temporary small fragment (in-fix) plate was removed and the site further thoroughly debrided. After this, the fracture is reduced and held with a new small fragment plate to facilitate the definitive intramedullary nailing. This new plate was either retained (RAP) as part of the definitive fixation at second stage or removed before wound coverage. MAIN OUTCOME MEASUREMENT: The main outcome measures were reoperation rate, deep infection, nonunion, and flap-related complication. RESULTS: Six patients (6/98, 6.1%) proceeded to nonunion (RAP 5/67, non-RAP 1/31). This was not significant (P = 0.416). Two hundred twelve operations were undertaken, and the median was 2. Sixteen (16/212, 7.5%) complication-related reoperations were undertaken, affecting 8 patients (8/67, 11.9%) in the RAP group. Eight patients (8/98, 8.2%) developed a deep infection (RAP 6/67, non-RAP 2/31). This was not significant (P = 0.674). CONCLUSIONS: In the context of an orthoplastic approach, the use of a RAP with definitive intramedullary nailing does not seem to significantly increase the rate of deep infection or nonunion in patients with type IIIB open tibial shaft fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The "FCR" Approach to the Knee for the Management of Posterior Tibial Plateau Fractures.

Three-column fixation of tibial plateau fractures is now an established philosophy. A direct posterior approach with the patient prone affords enhanced exposure of the posterior column and ease of access for fixation using a buttress plate and posterior-to-anterior screws. A "direct posterior" approach through a reverse L-shaped incision to back of the knee is popular, yet complications associated with raising a fascial flap can occur. We present a simple method of conceptualizing a direct posterior approach through a single longitudinal incision, by likening it to a commonly performed orthopedic approach, the flexor carpi radialis approach to the wrist.

Resuscitation in hip fractures: a systematic review.

To evaluate the evidence for the resuscitation of patients with hip fracture in the preoperative or perioperative phase of their treatment and its impact on mortality. DESIGN: We searched MEDLINE, EMBASE, CENTRAL and PROSPERO databases using a systematic search strategy for randomised trials and observational studies investigating the fluid resuscitation of any patient with hip fracture. No language limits were applied to the search, which was complemented by manually screening the reference lists of appropriate studies. OUTCOME MEASURES: Mortality at 1 week, 30 days and 1 year following surgery. RESULTS: Two hundred and ninety-eight citations were identified, and 12 full manuscripts were reviewed; no studies satisfied the inclusion criteria. The background literature showed that the mortality for these patients at 30 days is approximately 8.5% and that bone cement implantation syndrome is insufficient to explain this. The literature was explored to define the need for an interventional investigation into the preoperative resuscitation of patients with hip fracture. CONCLUSIONS: Patients with hip fracture show similar physiological disturbance to major trauma patients. Nineteen per cent of patients presenting with hip fracture are hypoperfused and 50% show preoperative anaemia suggesting that under resuscitation is a common problem that has not been investigated. A properly conducted interventional trial could improve the outcome of these vulnerable patients.

The association between the day of the week of milestones in the care pathway of patients with hip fracture and 30-day mortality: findings from a prospective national registry - The National Hip Fracture Database of England and Wales.

BACKGROUND: Recent publications indicate increased mortality in patients admitted to hospital at the weekend, but these findings may be subject to inadequate adjustment for case-mix and the complexities of resource provision. Hip fractures generally occur in a frail comorbid population with a consistent diagnosis precipitating admission as an emergency. We therefore aimed to examine the association between the day of the week of milestones in the care pathway and 30-day mortality in this population. METHODS: Using data from a prospective national database of hip fractures, we investigated the association between day of the week of admission, surgery, inpatient stay, and discharge (care pathway milestones) and 30-day mortality using generalised linear models. Data was collected between January 1, 2011, and December 31, 2014, on 241,446 patients. An incremental case-mix adjustment strategy was performed using patient characteristics, non-surgical interventions, surgical interventions and discharge characteristics. RESULTS: The day of admission was not associated with 30-day mortality. Sunday surgery (OR, 1.094; 95% CI, 1.043-1.148; P < 0.0001) and a delay to surgery of more than 24-hours (OR, 1.094; 95% CI, 1.059, 1.130; P < 0.0001) were both associated with a 9.4% increase in 30-day mortality. Discharge from the hospital on a Sunday (OR, 1.515; 95% CI, 1.224, 1.844; P < 0.0001) or out-of-hours discharge (OR, 1.174; 95% CI, 1.081, 1.276; P < 0.0001) were associated with a 51.5% and 17.4% increase in 30-day mortality, respectively. Mortality during the inpatient stay was 5.6% lower (IRR, 0.944; 95% CI, 0.909, 0.980; P = 0.003) at the weekend compared to weekdays. CONCLUSIONS: There is limited evidence of a generalised weekend effect in patients admitted to hospital for hip fracture. Optimising resource utilisation is an essential element of planning and delivering healthcare services. Interventions that lead to surgery within 24-hours of admission are justified. Factors such as Sunday operations, discharge and out-of-hours discharge require further investigation.

The effect of timing of antibiotic delivery on infection rates related to open limb fractures: a systematic review.

OBJECTIVE: To examine whether the timing of delivery of intravenous antibiotics following open limb fractures has an effect on deep infection rates and other outcomes. DESIGN: We published an a priori study protocol in PROSPERO. Our search strategy combined terms for antibiotics, timing of administration and fractures. Two independent reviewers screened, selected, assessed quality and extracted data from identified studies. DATA SOURCES: We searched five electronic databases with no limits and performed grey literature searches. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised and non-randomised controlled studies, prospective and retrospective observational studies in which the effect of the timing of delivery of antibiotics on the outcome of deep infection in open fractures was considered were included. RESULTS: Eight studies were included according to the above criteria. There were no randomised or non-randomised controlled trials. None of the included studies provided data on patient reported or health-related quality of life. The overall deep infection rate ranged from 5% to 17.5%. All of the studies were at substantial risk of bias. One study reported a reduced infection rate with the delivery of antibiotics within 66 min of injury and seven studies reporting no effect. CONCLUSIONS: Sufficiently robust evidence is not available currently to determine whether the timing of delivery of intravenous antibiotics has an effect on the risk of deep infection or other outcomes following open limb fractures. There is therefore a need for a randomised controlled trial in this area before policy changes should be instigated. TRIAL REGISTRATION NUMBER: PROSPERO (CRD42015016729).

Distal femoral fractures: The need to review the standard of care.

BACKGROUND: Hip fracture care has evolved, largely due to standardisation of practice, measurement of outcomes and the introduction of the Best Practice Tariff, leading to the sustained improvements documented by the National Hip Fracture Database (NHFD). The treatment of distal femoral fractures in this population has not had the same emphasis. This study defines the epidemiology, current practice and outcomes of distal femoral fractures in four English centres. PATIENTS AND METHODS: 105 patients aged 50 years or greater with a distal femoral fracture, presenting to four UK major trauma centres between October 2010 and September 2011 were identified. Data was collected using an adapted NHFD data collection tool via retrospective case note and radiograph review. Local ethics approval was obtained. RESULTS: Mean age was 77 years (range 50-99), with 86% female. 95% of injuries were sustained from a low energy mechanism, and 72% were classified as either 33-A1 or 33-C1. The mean Parker mobility score and Barthel Independence Index were 5.37 (0-9) and 75.5 (0-100) respectively. Operative management was performed in 84%, and 86% had their surgery within 36 h. Three quarters were fixed with a peri-articuar locking plate. There was no consensus on post operative rehabilitation, but no excess of complications in the centres where weight bearing as tolerated was the standard. 45% were seen by an orthogeriatrician during their admission. Mean length of stay was 29 days. Mortality at 30 days, 6 months, and 1 year was 7%, 16% and 18% respectively. DISCUSSION: This study demonstrates that the distal femoral and hip fracture populations are similar, and highlights the current disparity in their management. The metrics and standards of care currently applied to hip fractures should be applied to the treatment of distal femoral fractures. Optimal operative treatment and rehabilitation remains unclear, and is in need of further research.