Osteoporosis is a disease characterized by a decrease in bone mineral density, thereby increasing the risk of sustaining a fragility fracture. Most medical therapies are systemic and do not restore bone in areas of need, leading to undesirable side effects. Injectable hydrogels can locally deliver therapeutics with spatial precision, and this study reports the development of an injectable hydrogel containing a peptide mimic of bone morphogenetic protein-2 (BMP-2). To create injectable hydrogels, hyaluronic acid was modified with norbornene (HANor) or tetrazine (HATet) which upon mixing click into covalently crosslinked Nor-Tet hydrogels. By modifying HANor macromers with methacrylates (Me), thiolated BMP-2 mimetic peptides were immobilized to HANor via a Michael addition reaction, and coupling was confirmed with 1H NMR spectroscopy. BMP-2 peptides presented in soluble and immobilized form increased alkaline phosphatase (ALP) expression in MSCs cultured on 2D and encapsulated in 3D Nor-Tet hydrogels. Injection of bioactive Nor-Tet hydrogels into hollow intramedullary canals of Lewis rat femurs showed a local increase in trabecular bone density as determined by micro-CT imaging. The presented work shows that injectable hydrogels with immobilized BMP-2 peptides are a promising biomaterial for the local regeneration of bone tissue and for the potential local treatment of osteoporosis.

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Purpose Reducing waste is at the forefront for healthcare administrators, and one area to target is routine pre-operative testing. Despite the availability of professional/societal guidelines, physicians continue to order routine preoperative tests. Preoperative tests rarely influence surgical management, and there is data supporting safety without preoperative testing in low-risk surgeries for healthy patients. We believe these principles can be extrapolated to low-risk orthopedic procedures in healthy patients, such as isolated distal extremity fractures. We believe there will be enough wasted expenditure with unnecessary preoperative workup in isolated orthopedic trauma to warrant change in preoperative management. Methods A retrospective analysis of 209 cases of isolated distal extremity fractures from July 2019-July 2020 was conducted. Charts were queried for preoperative tests completed. Each case’s respective series of preoperative tests were compared to what professional/societal guidelines deemed appropriate. A decision-making analysis was performed to assess physician overordering. Total number of unnecessary tests was calculated, and cost analysis was completed to determine potential waste. Results 98% of cases had at least one unnecessary test. Coagulation profiles and blood type tests were the most commonly over-ordered tests at 90% of the time. Cost analysis revealed $262,624 in potentially wasted expenditure. Blood type tests and chest x-rays represented the largest portion, with $129,654 and $71,694 of wasted expenditure respectively. Conclusion We recommend the implementation of multimodal interventions in clinics treating these injuries. Interventions should include components of provider education, provider audit and feedback, and EMR ordering restrictions to reduce this area of waste.

Background We recently sought to integrate our orthopaedic and plastic hand surgeons with the goal of improving education, patient care, and providing seamless, continuous coverage for our trauma center. Our hypothesis was that integration could serve both the orthopaedic and plastic surgery training programs well and provide more consistent care for the trauma patients. Materials and Methods Program director approval was granted for blinded analysis of case logs from plastic and orthopaedic surgery programs from 2012 through 2019. Data on mean and total number of hand cases were analyzed and compared for both specialties. Institutional Review Board approval was granted for a retrospective review of patient outcomes. Results For both orthopaedic and plastics resident trainees, the mean number of hand cases increased during this study period suggesting that the integration had a favorable impact on both programs. The mean number of hand cases for orthopaedic residents rose from 163 to 246. The mean number of hand cases for plastic surgery residents rose from 218 to 295. Patient outcomes as reflected in length of stay and time to consultation also improved. Conclusion To improve hand surgical training and patient care, an integrated orthoplastics approach to hand surgery was implemented at our institution. Plastic surgery trainees are completing more hand surgery cases in an integrated model (p < 0.001), including fracture care (p < 0.047). Orthopaedic surgery trainees have doubled the percentage of integumentary and microsurgery cases in the integrated model (p < 0.001). The educational and clinical changes affected in an integrated model have changed the paradigm for educating future hand surgeons at our institution.

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