Mid to Long-Term Outcomes of Grade III-B Open Tibial Fractures Definitively Managed With a Circular Frame: A 13-Year Prospective Database Study at a Major Trauma Center.

OBJECTIVES: The aim of this study was to report experience of a major trauma center utilizing circular frames as definitive fixation in patients sustaining Gustilo-Anderson 3B open tibial fractures. DESIGN: A prospectively maintained database was retrospectively interrogated. SETTING: Single major trauma center in the United Kingdom. PATIENT SELECTION CRITERIA: All patients over the age of 16 sustaining an open tibial fracture with initial debridement performed at the study center. All patients also received orthoplastic care for a soft tissue defect (via skeletal deformation or a soft tissue cover procedure) and subsequent definitive management using an Ilizarov ring fixator. Patients who received primary debridement at another center, had preexisting infection, sustained a periarticular fracture, or those who did not afford a minimum of 12-month follow-up were excluded. Case notes and radiographs were reviewed to collate patient demographics and injury factors. OUTCOME MEASURES AND COMPARISONS: The primary outcome of interest was deep infection rate with secondary outcomes including time to union and secondary interventions. RESULTS: Two hundred twenty-five patients met inclusion criteria. Mean age was 43.2 year old, with 72% males, 34% smokers, and 3% diabetics. Total duration of frame management averaged 6.4 months (SD 7.7). Eight (3.5%) patients developed a deep infection and 41 (20%) exhibited signs of a pin site infection. Seventy-nine (35.1%) patients had a secondary intervention, of which 8 comprised debridement of deep infection, 29 bony procedures, 8 soft tissue operations, 30 frame adjustments, and 4 patients requiring a combination of soft tissue and bony procedures. Bony union was achieved in 221 cases (98.2%), 195 (86.7%) achieved union in a single frame without the need for secondary intervention, 26 required frame adjustments to achieve union. Autologous bone grafts were used in 10 cases. CONCLUSIONS: Orthoplastic care including circular frame fixation for Gustilo-Anderson-3B fractures of the tibia resulted in a low rate of deep infection (3.5%) and achieved excellent union rates (98.2%). LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Dynamic functional connectivity during task performance and rest predicts individual differences in attention across studies.

Dynamic functional connectivity (DFC) aims to maximize resolvable information from functional brain scans by considering temporal changes in network structure. Recent work has demonstrated that static, i.e. time-invariant resting-state and task-based FC predicts individual differences in behavior, including attention. Here, we show that DFC predicts attention performance across individuals. Sliding-window FC matrices were generated from fMRI data collected during rest and attention task performance by calculating Pearson's r between every pair of nodes of a whole-brain atlas within overlapping 10-60s time segments. Next, variance in r values across windows was taken to quantify temporal variability in the strength of each connection, resulting in a DFC connectome for each individual. In a leave-one-subject-out-cross-validation approach, partial-least-square-regression (PLSR) models were then trained to predict attention task performance from DFC matrices. Predicted and observed attention scores were significantly correlated, indicating successful out-of-sample predictions across rest and task conditions. Combining DFC and static FC features numerically improves predictions over either model alone, but the improvement was not statistically significant. Moreover, dynamic and combined models generalized to two independent data sets (participants performing the Attention Network Task and the stop-signal task). Edges with significant PLSR coefficients concentrated in visual, motor, and executive-control brain networks; moreover, most of these coefficients were negative. Thus, better attention may rely on more stable, i.e. less variable, information flow between brain regions.

Surgical waiting times and patient choice: how much delay do patients really want?

BACKGROUND: The 18-week target to treatment government initiative was implemented in 2004. In order for this to work, patients need to accept operative dates provided, otherwise the pathway will fail. AIM: The aim of this prospective study was to identify the earliest time patients would accept surgical intervention following assessment at an outpatient clinic and to identify the reasons why some patients would choose to delay surgery. METHODS: This prospective study was carried out at an elective orthopaedic centre over a 5-month period. All new adult referrals to the department were asked to complete a seven-point questionnaire on waiting time preference and possible reasons for delaying surgery. No paediatric or spinal orthopaedics was carried out at the centre. RESULTS: A total of 73 % of the 797 questionnaires were completed. Up to 16 % of patients could not accept day-case/inpatient operation within 6 weeks. Work commitment was the most common reason for choosing to delay surgery, with nearly 50 % of employed patients citing it as a reason. No significant difference was identified between inpatient and day-case procedures. CONCLUSION: There is a risk that operative slots will be unfilled within the 18-week pathway. 18 % of patients will potentially refuse an operative date offered within 6 weeks of their outpatient visit. Work, holidays and care arrangements are important in uptake. A proactive strategy to improve the uptake of offered surgery is required to prevent operating slots being underutilised.