Hands-free Femoral Traction Using the Bookwalter Retractor System During Anterior Approaches to the Acetabulum.

SUMMARY: Displaced acetabular fractures with medial and cranial displacement of the femoral head commonly require an anterior approach for reduction and stabilization. Restoration of the femoral head to its native position under the reduced acetabular dome is a primary goal of surgery. We present a surgical technique for applying traction to the proximal femur using the Bookwalter retractor system during the repair of acetabular fractures when using an anterior approach. By placing traction in line with the femoral neck, the femoral head is moved to a more anatomical position allowing acetabular fracture fragments to be reduced unimpeded and the femoral head may be used as a reconstructive template. We review a case series of 116 patients treated using this technique and report the short- and long-term radiographic and clinical results of treatment.

Injury Pattern Recognition and Surgical Technique of Pilon Fracture Reduction With Posterior Tibial Tendon Incarceration.

SUMMARY: Pilon fractures occur over a broad spectrum of injury severity and soft-tissue compromise. This article will review a distinct pilon injury variant characterized by posterior tibial tendon incarceration in posteromedial pilon fracture propagation. This injury pattern is vital to recognize preoperatively because failure to mobilize the entrapped posterior tibial tendon (PTT) will result in fracture malreduction and postoperative loss of PTT excursion. In addition, the authors' preferred surgical technique for PTT mobilization and anatomic fracture reduction is described.

Statistical Literacy in the Orthopaedic Trauma Population.

OBJECTIVE: To evaluate the baseline level and demographic predictors of statistical literacy in orthopaedic patients who sustained traumatic injuries. DESIGN: Prospective observational. SETTING: Level 1 trauma center. PATIENTS: One hundred ninety-eight patients presenting to the orthopaedic trauma clinic. INTERVENTION: Berlin Numeracy Test (BNT) and General Health Numeracy Test-6 (GHNT-6). RESULTS: When assessed using the BNT, 67% of patients had results that placed them into the lowest quartile of objective numeracy skills. Only 3.5% of patients had results that scored in the top quartile. Our multivariate ordinal regression model demonstrated lower education level ( P = 0.01), and older age ( P = 0.03) were significant predictors of poor performance on the BNT. The mean score on the GHNT-6 was 36% (SD 30%). CONCLUSIONS: In a cohort of traumatically injured patients, poor statistical literacy was common, occurring in more than two-thirds of patient surveyed. Older age and lower levels of education were predictive of poor BNT performance and should be considered when discussing surgical options, associated risks, and likelihood of potential complications.

Extra-articular Unstable Iliac Fractures: Associated Injuries, Fixation Strategies, and Outcomes.

OBJECTIVE: To characterize the associated injuries, fixation constructs, and outcomes of extra-articular unstable iliac fractures. DESIGN: Retrospective cohort study. SETTING: Level I trauma center. PATIENTS: Thirty-three extra-articular unstable iliac fractures treated over a 20-year period. INTERVENTION: Percutaneous or open fixation of iliac fractures at the pelvic brim AND/OR iliac crest. MAIN OUTCOME MEASURES: Incidence of union, fixation failure, and angiography at the time of injury. RESULTS: Twenty-five patients were treated operatively with appropriate follow-up. Four patients had fixation failure with displacement, all in the group with only brim OR crest fixation (4/8 patients, 50% rate). In patients with both crest AND brim fixation (n = 17), there were no cases of implant failure or late displacement. In displaced fractures (n = 22), 4 patients (18%) required embolization by interventional radiology. In all 4 cases, the superior gluteal artery was embolized. In patients with both crest AND brim fixation, all went on to uneventful union with an average Visual Analog Scale (VAS) pain score of 0.9 (range, 0-5) at final follow-up. CONCLUSIONS: Extra-articular unstable iliac fractures are high-energy injuries that demonstrate a high rate of union when both pelvic brim AND iliac crest fixation is used. Approximately 1 in 5 patients with a displaced iliac fracture presented with a superior gluteal artery disruption requiring embolization. Pelvic brim OR iliac crest fixation used in isolation was associated with a fixation failure rate of 50%, supporting previous biomechanical work. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Leech (Myzobdella lugubris) infestations in largemouth bass (Micropterus salmoides) in Back Bay, Virginia, USA.

Back Bay is an oligohaline, coastal bay in southeast Virginia, USA. Since 2004, leeches have been observed in the oral cavities of largemouth bass (Micropterus salmoides) in this body of water. Leeches (Myzobdella lugubris) have previously been documented in the oral cavities of largemouth bass in the Currituck Sound, which is confluent with Back Bay on its southern border. Supplemental stocking of largemouth bass in Back Bay since 2009 has resulted in an increasing population; however, concern exists that leech infestation may be negatively affecting health of larger fish, which are still less abundant than expected. Despite the wide distribution of this leech, there is little available literature regarding its health impacts on hosts. In this study, we examine potential impacts of oral leech infestations on stress markers and haematological parameters of largemouth bass in Back Bay. No significant changes in plasma glucose or cortisol were observed between leech-infested and uninfested fish, and haematological parameters were not significantly different between the groups. Further, there was no evidence of systemic infections associated with leech infestation.

Association Between 6-Week Postdischarge Risk Classification and 12-Month Outcomes After Orthopedic Trauma.

Importance: Numerous studies have demonstrated that long-term outcomes after orthopedic trauma are associated with psychosocial and behavioral health factors evident early in the patient's recovery. Little is known about how to identify clinically actionable subgroups within this population. Objectives: To examine whether risk and protective factors measured at 6 weeks after injury could classify individuals into risk clusters and evaluate whether these clusters explain variations in 12-month outcomes. Design, Setting, and Participants: A prospective observational study was conducted between July 16, 2013, and January 15, 2016, among 352 patients with severe orthopedic injuries at 6 US level I trauma centers. Statistical analysis was conducted from October 9, 2017, to July 13, 2018. Main Outcomes and Measures: At 6 weeks after discharge, patients completed standardized measures for 5 risk factors (pain intensity, depression, posttraumatic stress disorder, alcohol abuse, and tobacco use) and 4 protective factors (resilience, social support, self-efficacy for return to usual activity, and self-efficacy for managing the financial demands of recovery). Latent class analysis was used to classify participants into clusters, which were evaluated against measures of function, depression, posttraumatic stress disorder, and self-rated health collected at 12 months. Results: Among the 352 patients (121 women and 231 men; mean [SD] age, 37.6 [12.5] years), latent class analysis identified 6 distinct patient clusters as the optimal solution. For clinical use, these clusters can be collapsed into 4 groups, sorted from low risk and high protection (best) to high risk and low protection (worst). All outcomes worsened across the 4 clinical groupings. Bayesian analysis shows that the mean Short Musculoskeletal Function Assessment dysfunction scores at 12 months differed by 7.8 points (95% CI, 3.0-12.6) between the best and second groups, by 10.3 points (95% CI, 1.6-20.2) between the second and third groups, and by 18.4 points (95% CI, 7.7-28.0) between the third and worst groups. Conclusions and Relevance: This study demonstrates that during early recovery, patients with orthopedic trauma can be classified into risk and protective clusters that account for a substantial amount of the variance in 12-month functional and health outcomes. Early screening and classification may allow a personalized approach to postsurgical care that conserves resources and targets appropriate levels of care to more patients.

Does Admission to Medicine or Orthopaedics Impact a Geriatric Hip Patient's Hospital Length of Stay?

OBJECTIVES: The aim of our study was to determine the association between admitting service, medicine or orthopaedics, and length of stay (LOS) for a geriatric hip fracture patient. DESIGN: Retrospective. SETTING: Urban level 1 trauma center. PATIENTS/PARTICIPANTS: Six hundred fourteen geriatric hip fracture patients from 2000 to 2009. INTERVENTIONS: Orthopaedic surgery for geriatric hip fracture. MAIN OUTCOME MEASUREMENTS: Patient demographics, medical comorbidities, hospitalization length, and admitting service. Negative binomial regression used to determine association between LOS and admitting service. RESULTS: Six hundred fourteen geriatric hip fracture patients were included in the analysis, of whom 49.2% of patients (n = 302) were admitted to the orthopaedic service and 50.8% (3 = 312) to the medicine service. The median LOS for patients admitted to orthopaedics was 4.5 days compared with 7 days for patients admitted to medicine (P < 0.0001). Readmission was also significantly higher for patients admitted to medicine (n = 92, 29.8%) than for those admitted to orthopaedics (n = 70, 23.1%). After controlling for important patient factors, it was determined that medicine patients are expected to stay about 1.5 times (incidence rate ratio: 1.48, P < 0.0001) longer in the hospital than orthopaedic patients. CONCLUSIONS: This is the largest study to demonstrate that admission to the medicine service compared with the orthopaedic service increases a geriatric hip fractures patient's expected LOS. Since LOS is a major driver of cost as well as a measure of quality care, it is important to understand the factors that lead to a longer hospital stay to better allocate hospital resources. Based on the results from our institution, orthopaedic surgeons should be aware that admission to medicine might increase a patient's expected LOS. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Acute Management of Traumatic Knee Dislocations for the Generalist.

Acute knee dislocations are an uncommon injury that can result in profound consequences if not recognized and managed appropriately on presentation. Patients presenting with knee pain in the setting of high- or low-energy trauma may have sustained a knee dislocation that spontaneously reduced. Prompt reduction of the dislocated knee and serial neurovascular examinations are paramount. Damage to the popliteal artery is a common associated injury that can be diagnosed on physical examination using ankle brachial indices (ABIs), CT angiography, or standard angiography. After reduction, patients with a normal pulse examination and an ABI ≥0.9 may be observed, with serial examination performed to document vascular status and monitor for compartment syndrome. Patients with asymmetric pulses or an ABI <0.9 in the presence of pulses may be treated urgently depending on the results of additional vascular imaging, and patients with absent pulses and clear signs of vascular compromise should be treated emergently. Some knee dislocations are not reducible and should be taken emergently to the operating room for an open reduction. Persistent joint subluxation or severe soft-tissue injuries after reduction require temporary external fixation before definitive repair or reconstruction of ligaments is performed.

A comparison of the Indian Health Service counseling technique with traditional, lecture-style counseling.

OBJECTIVES: To compare the immediate postcounseling retention of important information using the traditional method with retention obtained using the Indian Health Service (IHS) interactive technique, and to compare the time required to counsel patients on new prescriptions using the traditional method with the time required using the IHS technique. DESIGN: A prospective, nonrandomized, observational study at four different local community pharmacies in Oregon. Two sites that used the traditional counseling model served as the control sites, while two other sites used the IHS counseling model. Only new prescriptions were included in this study. The pharmacists did not alter their counseling styles for new prescriptions for the purposes of this study. The duration of counseling between the pharmacist and patient was recorded. Immediately upon completion of counseling, patients met with the primary investigator for postcounseling knowledge assessment on indication of therapy, directions on how to take their medication properly, and expected adverse effects. SETTING: Four local community pharmacies in Oregon. PARTICIPANTS: Five hundred patients at four local community pharmacies in Oregon. INTERVENTION: Use of the IHS counseling technique. MAIN OUTCOME MEASURES: Immediate recall of key counseling points and time per counseling session. RESULTS: A total of 500 patients participated in the study. Seventy-one percent of patients counseled using the IHS technique answered all three questions correctly, compared with 33% of patients counseled using the traditional method (P <0.00). For patients who were counseled about adverse effects, 80% counseled using the IHS technique compared with 51.5% counseled using the traditional approach answered all three questions correctly. For indication of therapy, there was no evidence of a difference in the proportion of correct answers between counseling types on the reason for taking their medication (P = 0.06). Those who received IHS counseling had four times the odds of correctly answering when to take their medication and four times the odds of correctly answering all adverse effects questions. The duration of counseling methods differed by 53 seconds (128 s for IHS vs. 75 s for traditional). CONCLUSION: The interactive style of the IHS method of counseling provided significantly improved immediate memory recall compared with the traditional method. The IHS method also took longer than the traditional method.

Operative intervention for geriatric hip fracture: does type of surgery affect hospital length of stay?

Hip fractures are the most costly fall-related fractures. Differences in hospital length of stay (LOS) based on type of surgery could have major financial implications in a potential bundled payment system in which all hip fractures are reimbursed a standard amount. We conducted a study to analyze differences in hospital LOS and costs for total hip arthroplasty (THA), hemiarthroplasty (HA), cephalomedullary nailing, open reduction and internal fixation (ORIF), and closed reduction and percutaneous pinning (CRPP). Through retrospective chart review, 615 patients over age 60 years across a 9-year period at an urban level I trauma center were identified. Mean LOS and costs for hip fracture repair were 6.91 days and $30,011.25, respectively. HA/THA was associated with the longest mean LOS (7.43 days) and highest costs ($33,657.90). After several patient factors were adjusted for, ORIF was associated with 0.84 fewer in-patient days and $3805.20 less in hospitalization costs compared with HA/THA (P=.042). CRPP was associated with 1.63 fewer days and $7383.90 less in costs than HA/THA (P=.0076). Our results provide insight into the financial implications of hip fracture fixation and identify targets for quality improvement initiatives to improve efficiency of resource utilization.

Behavioral correlates of maternal antibody status among children with autism.

Autism spectrum disorders (ASDs) affect approximately 1 in 110 children in the United States. This report profiles fetal-brain reactive autoantibodies of a large cohort of mothers of children with autism and controls, yielding significant associations between the presence of IgG reactivity to fetal brain proteins at 37 and 73 kDa and a childhood diagnosis of full autism (p = 0.0005), which also correlated with lower expressive language scores (p = 0.005). Additionally, we report on reactivity to proteins at 39 and 73 kDa, which correlated with the broader diagnosis of ASD (p = 0.0007) and increased irritability on the Aberrant Behavioral Checklist (p = 0.05). This study provides evidence of multiple patterns of reactivity to fetal brain proteins by maternal antibodies associated with ASD and specific childhood behavioral outcomes.

Autoantibodies to cerebellum in children with autism associate with behavior.

Autism is a heterogeneous disorder with a poorly understood biological basis. Some children with autism harbor plasma autoantibodies that target brain proteins. Similarly, some mothers of children with autism produce antibodies specific to autism that target pairs of fetal brain proteins at 37/73 and 39/73 kDa. We explored the relationship between the presence of brain-specific autoantibodies and several behavioral characteristics of autism in 277 children with an autism spectrum disorder and 189 typically developing age-matched controls. Further, we used maternal autoantibody data to investigate potential familial relationships for the production of brain-directed autoantibodies. We demonstrated by Western blot that autoantibodies specific for a 45 kDa cerebellar protein in children were associated with a diagnosis of autism (p=0.017) while autoantibodies directed towards a 62 kDa protein were associated with the broader diagnosis of autism spectrum disorder (ASD) (p=0.043). Children with such autoantibodies had lower adaptive (p=0.0008) and cognitive function (p=0.005), as well as increased aberrant behaviors (p<0.05) compared to children without these antibodies. No correlation was noted for those mothers with the most specific pattern of anti-fetal brain autoantibodies and children with the autoantibodies to either the 45 or 62 kDa bands. Collectively, these data suggest that antibodies towards brain proteins in children are associated with lower adaptive and cognitive function as well as core behaviors associated with autism. It is unclear whether these antibodies have direct pathologic significance, or if they are merely a response to previous injury. Future studies are needed to determine the identities of the protein targets and explore their significance in autism.

Comparison of two methods of assessing dairy cow body condition score.

Two body condition scoring systems were compared for assessing body condition of cows at the Scottish Agricultural College's Crichton Royal Farm. The weekly body condition scores (BCS) were collected for a period of 12 weeks (5 September-21 November). Scores were obtained using the primary systems utilized within the UK and USA. The USBCS were obtained by the same evaluator each week, while the UKBCS were obtained by two different evaluators alternating between weeks. Paired scores (n=2088) between the two systems within week were moderately correlated (r=0.75, P<0.0001). Regression equations to convert scores between the two systems were created using the GLM procedure of SAS (SAS Institute Inc., Cary NC, USA). The simple GLM models to convert from UK to US scores and US to UK scores were USBCS=1.182+0.816 * UKBCS (R2=0.56) and UKBCS=0.131+0.681 (R2=0.56), respectively. These equations may be used to interpret scores within the literature obtained using these two BCS systems, although they must be used with caution.

Influence of milk yield, stage of lactation, and body condition on dairy cattle lying behaviour measured using an automated activity monitoring sensor.

Time spent lying by lactating Holstein-Friesian cows of varying body condition scores (BCS) and milk yield was measured using an animal activity monitor. A 3-week average BCS was calculated for each cow; and in total, 84 cows were selected with 28 cows each among three BCS categories (Thin: BCS<2.75; Moderate: 2.75 > or = BCS<3.25; Heavy: BCS> or = 3.25) and two stage of lactation categories (<150 days in milk or >150 days in milk). Cows were kept in two management systems: parlour/freestall (n=60) or automated milking system/freestall (n=24). Behaviour was recorded for 5.3+/-0.1 d for each cow. Production levels were considered using a 28-d rolling average of daily milk production. Cows that exhibited clinical lameness before or during the observation period were excluded from analyses. For cows exhibiting oestrus, the day prior to, day of, and day following breeding were removed. The final analysis included 77 cows (408 d of observation). A mixed model was fitted to describe average daily hours spent lying. Results demonstrated that lying time increased as days in milk (DIM) increased (P=0.05). Variables that were tested but not significant (P>0.05) were BCS category, parity category (1 or 2) and 28-d rolling average daily milk production. Although a numerical trend for increasing hours spent lying with increasing BCS was observed, after accounting for other factors in the mixed model, BCS did not significantly impact lying time. Continued investigation of these management factors that impact lying time and bouts, using new technologies, more cows, and more herds will help dairy owners better manage facilities and cow movements to optimize this essential behaviour.

Longitudinal changes in strength of police officers with gender comparisons.

Strength is a critical factor in the health and job performance of police officers. Using a retrospective longitudinal design, the purpose of this study was to identify differences in strength scores from initial recruitment to in-service tests and to compare gender differences. Strength changes were also compared in low- to high-strength groups. Strength scores included bench press, bench press/lean weight, and bench press/weight. Body weight, percent body fat, and bench press scores were retrieved for the 1990-1995 recruit classes and were paired to most recent scores on 2006 in-service fitness record. Sample included 327 police officers: 30 females and 297 males. Mean age at initial recruitment was 24.6 years and for in-service was 37.1 years. Average time between tests was 12.5 years. Over this period bench press and bench press/lean weight significantly increased for both gender groups (p

Physical activity, weight gain and occupational health among call centre employees.

BACKGROUND: A need exists to address ergonomic, weight gain and obesity risks in sedentary occupations. AIM: To determine relationships between body mass index (BMI), weight gain, ergonomic and exercise variables in sedentary workers. METHODS: An anonymous questionnaire was administered regarding body weight, height, weight gained since employment, body part discomfort, shift fatigue, time to achieve job adaptation, physical activity, fitness centre membership, previous employment type and previous injury. RESULTS: Subjects were 393 volunteers (mean age 34 years, 71% female) employed in a call centre. Sixty-eight per cent of participants gained weight averaging 0.9 kg/month for 8 months. Significant findings (P < 0.05) were as follows: non-obese individuals gained less weight than obese individuals, fitness club members had higher BMIs and weight gains than non-members, previously injured individuals gained more weight than non-injured individuals, non-weight gainers reported higher metabolic equivalent-min/week expenditure in relation to vigorous exercise. CONCLUSIONS: Participants reported substantial weight gain over a period of 8 months. In contrast to walking and moderate exercise, only vigorous exercise was significantly associated with non-weight gain. Three risk factors were identified for weight gain: obese when hired, history of previous injury and lack of vigorous exercise.

Unilateral external ophthalmoplegia in Miller Fisher syndrome: case report.

BACKGROUND: A description of the diagnostic features of Miller Fisher syndrome. CASE PRESENTATION: The clinical presentation, investigation, and subsequent progress of our patient with clinical unilateral external ophthalmoplegia. CONCLUSION: Our case demonstrates the presentation of clinical unilateral external ophthalmoplegia as part of the full triad of Miller Fisher syndrome.