Serpentoviruses in Free-Ranging Shingleback Skinks (Tiliqua rugosa) in Western Australia and South Australia, Australia.

Serpentoviruses are strongly associated with upper respiratory tract disease in captive and free-ranging bluetongued skinks (Tiliqua spp.). In Australia, bluetongue serpentoviruses were first reported in shingleback skinks (Tiliqua rugosa) with upper respiratory tract disease that presented to wildlife rehabilitation facilities in Perth, Western Australia. Since then, serpentoviruses have been detected commonly in captive bluetongued skinks from most areas of Australia, yet knowledge about the prevalence and distribution of these viruses in free-ranging bluetongued skinks, and other skink species, remains limited. Oral swabs were collected from 162 shingleback skinks from four areas in Western Australia and neighboring South Australia to screen for bluetongue serpentoviruses by PCR. The proportions of PCR positives were 0% (0/4) for Rottnest Island (a small island west of Perth, Western Australia), 3% (1/32) for the Shire of Kent (∼5,600 km2 in the southwest of Western Australia), 1% (1/91) from an approximately 250,000 km2 area across southern Southern Australia and Western Australia, and 0% (0/35) from Mount Mary (∼150 km2 in the Mid North of South Australia). Neither of the two PCR-positive shingleback skinks had overt signs of upper respiratory tract disease. These results are consistent with serpentoviruses occurring at a relatively low crude prevalence of 1.4% (95% confidence interval, 0.2-4.9%) across these areas, although the potential bias from sampling active and apparently healthy individuals may mean that this estimate is lower than the true prevalence. This contrasts with the high proportion of PCR positives reported in captive individuals. In the absence of experimental or observational data on viral clearance and recovery, Tiliqua spp. skinks that are intended for release into the wild should be housed with strict biosecurity to prevent interactions with captive individuals and screened to ensure that they are not PCR positive before release.

Liver surface depressions in the presence of diaphragmatic muscular bands on trans-illumination.

Traditional descriptions of liver anatomy refer to a smooth, convex surface contacting the diaphragm. Surface depressions are recognized anatomic variants. There are many theories to explain the cause of the depressions. We discuss the theory that these are caused by hypertrophic muscular bands in the diaphragm.

Hepatic grooves: An observational study at laparoscopic surgery.

BACKGROUND: In traditional descriptions, the upper surface of the liver is smooth and convex, but deep depressions are variants that are present in 5%-40% of patients. We sought to determine the relationship between surface depressions and the diaphragm. AIM: To use exploratory laparoscopy to determine the relationship between surface depressions and the diaphragm. METHODS: An observational study was performed in all patients undergoing laparoscopic upper gastro-intestinal operations between January 1, 2023 and January 20, 2024. A thirty-degree laparoscope was used to inspect the liver and diaphragm. When surface depressions were present, we recorded patient demographics, presence of diaphragmatic bands, rib protrusions and/or any other source of compression during inspection. RESULTS: Of 394 patients, 343 had normal surface anatomy, and 51 (12.9%) had prominent surface depressions on the liver. There was no significant relationship between the presence of surface depressions and gender nor the presence of rib projections. However, there was significant association between the presence of surface depressions and diaphragmatic muscular bands (P < 0.001). CONCLUSION: With these data, the diaphragmatic-band theory has gained increased importance over other theories for surface depressions. Further studies are warranted using cross sectional imaging to confirm relationships with intersectional planes as well as beta-catenin assays in the affected liver parenchyma.

Integrated Dual Lag Screws Have Higher Reoperation Rates for Fixation Failure Than Single Lag Component Cephalomedullary Nails: A Retrospective Study of 2,130 Patients with Intertrochanteric Femoral Fractures.

BACKGROUND: Previous studies comparing reoperation risk between integrated dual lag screw (IDL) and single lag component (SL) cephalomedullary nails (CMNs) in the treatment of intertrochanteric femoral fractures have demonstrated mixed results. The purpose of this study was to assess the rates of reoperation for fixation failure and all-cause reoperation in a large, multi-institutional cohort of patients with an intertrochanteric fracture treated with an IDL or SL CMN. We hypothesized that there would be no difference between the groups with respect to either of the reoperation rates. METHODS: Adults (≥18 years old) who sustained an intertrochanteric fracture (AO/OTA 31A1 to 31A3) treated with an IDL or SL CMN between January 2014 and May 2021 at 1 of 13 Level-I trauma centers were included. Patients with <3 months of follow-up or pathologic fractures were excluded. Rates of reoperation were compared with use of the chi-square test and multivariable regression, controlling for age, gender, injury mechanism, fracture pattern, and postoperative neck-shaft angle. RESULTS: A total of 2,130 patients met the inclusion criteria. The median age was 78 years, and 62.5% of patients were female. The cohort consisted of 287 patients (13.5%) with an IDL CMN and 1,843 patients (86.5%) with an SL CMN. A total of 99 patients (4.6%) had a reoperation of any type, of whom 29 (1.4% of all patients) had a reoperation for fixation failure. Compared with patients with an SL CMN, those with an IDL CMN had higher rates (4.2% versus 0.9%; p < 0.001) and odds (odds ratio [OR], 4.95 [95% confidence interval (CI), 2.29 to 10.69]; p < 0.001) of reoperation for fixation failure as well as higher rates (7.3% versus 4.2%; p = 0.021) and odds (OR, 1.83 [95% CI, 1.10 to 3.06]; p = 0.021) of all-cause reoperation. CONCLUSIONS: Intertrochanteric femoral fractures treated with an IDL CMN were associated with low but significantly higher rates and significantly higher odds of reoperation for fixation failure and all-cause reoperation compared with those treated with an SL CMN. We suggest caution to surgeons in the use of IDL CMNs for high-risk patients and recommend using SL CMNs for most patients with intertrochanteric femoral fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Remote Summer Research Program to Improve Opportunity and Mentorship for Underrepresented Students With Interest in Orthopaedic Surgery: 3-Year Experiences.

INTRODUCTION: Medical students are challenged with a limited number of research opportunities to help prepare for an exceptionally competitive process for matching in an orthopaedic residency. The aim of this study was to assess the 3-year experience of our 8 to 10-week remote summer research program in support of underrepresented students with an interest in orthopaedic surgery. METHODS: We received over 500 applications, and a total of 37 students (7.4%) participated in the program over the past 3 years. A total of 14 faculty mentors were matched with 1 or 2 students each. The research program delivered a curriculum including (1) research-related topics led by a content expert; (2) weekly faculty lectures discussing topics including orthopaedic conditions, diversity in orthopaedics, leadership, and work-life balance; and (3) a minimum of 8 weeks of mentorship experience with an assigned faculty and a peer mentor. Students and faculty were surveyed to measure skill progression, research productivity, and program satisfaction. RESULTS: Program participants represented a range of race/ethnic backgrounds and research experience levels. The cohort included a high rate of female (51%) and Black (35%) participants relative to representation of these groups in orthopaedic surgery. Postprogram surveys indicated that all participants improved their research skills, orthopaedic interest, and mentorship/networking skills. Most students (89%) stated that they were adequately matched to their faculty mentor. Most students (79%) indicated that they contributed to either manuscript or conference abstract as coauthors. DISCUSSION: The study findings suggest improved research skills, interest, and confidence to pursue orthopaedic residency and mentorship/networks in the field. Our long-term vision is to improve the accessibility and quality of mentorship for underrepresented students to foster an equitable pathway into the field of orthopaedic surgery.

Treatment Failure After Repair of Displaced Femoral Neck Fractures in Patients Compared by "Decade of Life": An Analysis of 565 Cases in Adults Less Than 60 years of Age.

OBJECTIVES: To study the results of displaced femoral neck fractures (FNFs) in adults less than 60 years of age by comparing patients, injury, treatment, and the characteristics of treatment failure specifically according to patients' age at injury, that is, by their "decade of life" [ie, "under 30" (29 years and younger), "the 30s" (30-39 years), "the 40s" (40-49 years), and "the 50s" (50-59 years)]. DESIGN: Multicenter retrospective comparative cohort series. SETTING: Twenty-six North American Level 1 Trauma Centers. PATIENT SELECTION CRITERIA: Skeletally mature patients aged 18-59 years with operative repair of displaced FNFs. OUTCOME MEASURES AND COMPARISONS: Main outcome measures were treatment failures (fixation failure and/or nonunion, osteonecrosis, malunion, and the need for subsequent major reconstructive surgery (arthroplasty or proximal femoral osteotomy). These were compared across decades of adult life through middle age (<30 years, 30-39 years, 40-49 years, and 50-59 years). RESULTS: Overall, treatment failure was observed in 264 of 565 (47%) of all hips. The mean age was 42.2 years, 35.8% of patients were women, and the mean Pauwels angle was 53.8 degrees. Complications and the need for major secondary surgeries increased with each increasing decade of life assessed: 36% of failure occurred in patients <30 years of age, 40% in their 30s, 48% in their 40s, and 57% in their 50s (P < 0.001). Rates of osteonecrosis increased with decades of life (under 30s and 30s vs. 40s vs. 50s developed osteonecrosis in 10%, 10%, 20%, and 27% of hips, P < 0.001), while fixation failure and/or nonunion only increased by decade of life to a level of trend (P = 0.06). Reparative methods varied widely between decade-long age groups, including reduction type (open vs. closed, P < 0.001), reduction quality (P = 0.030), and construct type (cannulated screws vs. fixed angle devices, P = 0.024), while some variables evaluated did not change with age group. CONCLUSIONS: Displaced FNFs in young and middle-aged adults are a challenging clinical problem with a high rate of treatment failure. Major complications and the need for complex reconstructive surgery increased greatly by decade of life with the patients in their sixth decade experiencing osteonecrosis at the highest rate seen among patients in the decades studied. Interestingly, treatments provided to patients in their 50s were notably different than those provided to younger patient groups. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Optimal Fixation Strategies for Displaced Femoral Neck Fractures in Patients 18-59 Years of Age: An Analysis of 565 Cases Treated at 26 Level 1 Trauma Centers.

OBJECTIVES: The objective of this study was to determine the difference in failure rates of surgical repair for displaced femoral neck fractures in patients younger than 60 years of age according to fixation strategy. DESIGN: This is a retrospective, comparative cohort study. SETTING: Twenty-six Level 1 North American trauma centers. PATIENT SELECTION CRITERIA: Patients younger than 60 years of age with a displaced femoral neck fracture (OTA 31-B2, B3) undergoing surgical repair from 2005 to 2017. OUTCOME MEASURES AND COMPARISONS: Patient demographics, injury characteristics, repair methods used, and treatment failure (nonunion/failed fixation, avascular necrosis, and need for secondary surgery) were compared according to fixation strategy. RESULTS: Five hundred and sixty-five patients met inclusion criteria and were studied. The mean age was 42 years, 36% were female, and the average Pauwels' angle of fractures was 55 degrees. There were 305 patients treated with multiple cannulated screws (MCS) and 260 treated with a fixed-angle (FA) construct. Treatment failures were 46% overall, but was more likely to occur in MCS constructs versus FA devices (55% vs. 36%, P < 0.001). When FA constructs were substratified, the use of a sliding hip screw with addition of a medial femoral neck buttress plate (FNBP) and "antirotation" (AR) screw demonstrated better results than either FNBP or AR screw alone or neither with the lowest overall construct failure rate of 11% (P < 0.036). CONCLUSIONS: Historically used fixation constructs for femoral neck fractures (eg, multiple cannulated screws and sliding hip screw) in young and middle-aged adults performed poorly compared with more recently proposed constructs, including those using a medial femoral neck buttress plate and an antirotation screw. Fixed-angle constructs outperformed multiple cannulated screws overall, and augmentation of fixed-angle constructs with a medial femoral neck buttress plate and antirotation screw improved the likelihood of successful treatment. Surgeons should prioritize fixation decisions when repairing displaced femoral neck fractures in patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Femoral Neck Fractures With Associated Ipsilateral Femoral Shaft Fractures in Young Adults <50 Years Old: A Multicenter Comparison of 80 Cases Versus Isolated Femoral Neck Fractures.

OBJECTIVES: To analyze patients, injury patterns, and treatment of femoral neck fractures (FNFs) in young patients with FNFs associated with shaft fractures (assocFNFs) to improve clinical outcomes. The secondary goal was to compare this injury pattern to that of young patients with isolated FNFs (isolFNFs). DESIGN: Retrospective multicenter cohort series. SETTING: Twenty-six North American level-1 trauma centers. PATIENT SELECTION CRITERIA: Skeletally mature patients, <50 years old, treated with operative fixation of an FNF with or without an associated femoral shaft fracture. OUTCOME MEASURES AND COMPARISONS: The main outcome measurement was treatment failure defined as nonunion, malunion, avascular necrosis, or subsequent major revision surgery. Odds ratios for these modes of treatment were also calculated. RESULTS: Eighty assocFNFs and 412 isolFNFs evaluated in this study were different in terms of patients, injury patterns, and treatment strategy. Patients with assocFNFs were younger (33.3 ± 8.6 vs. 37.5 ± 8.7 years old, P < 0.001), greater in mean body mass index [BMI] (29.7 vs. 26.6, P < 0.001), and more frequently displaced (95% vs. 73%, P < 0.001), "vertically oriented" Pauwels type 3, P < 0.001 (84% vs. 43%) than for isolFNFs, with all P values < 0.001. AssocFNFs were more commonly repaired with an open reduction (74% vs. 46%, P < 0.001) and fixed-angle implants (59% vs. 39%) (P < 0.001). Importantly, treatment failures were less common for assocFNFs compared with isolFNFs (20% vs. 49%, P < 0.001) with lower rates of failed fixation/nonunion and malunion (P < 0.001 and P = 0.002, respectively). Odds of treatment failure [odds ratio (OR) = 0.270, 95% confidence interval (CI), 0.15-0.48, P < 0.001], nonunion (OR = 0.240, 95% CI, 0.10-0.57, P < 0.001), and malunion (OR = 0.920, 95% CI, 0.01-0.68, P = 0.002) were also lower for assocFNFs. Excellent or good reduction was achieved in 84.2% of assocFNFs reductions and 77.1% in isolFNFs (P = 0.052). AssocFNFs treated with fixed-angle devices performed very well, with only 13.0% failing treatment compared with 51.9% in isolFNFs treated with fixed-angle constructs (P = <0.001) and 33.3% in assocFNFs treated with multiple cannulated screws (P = 0.034). This study also identified the so-called "shelf sign," a transverse ≥6-mm medial-caudal segment of the neck fracture (forming an acute angle with the vertical fracture line) in 54% of assocFNFs and only 9% of isolFNFs (P < 0.001). AssocFNFs with a shelf sign failed in only 5 of 41 (12%) cases. CONCLUSIONS: AssocFNFs in young patients are characterized by different patient factors, injury patterns, and treatments, than for isolFNFs, and have a relatively better prognosis despite the need for confounding treatment for the associated femoral shaft injury. Treatment failures among assocFNFs repaired with a fixed-angle device occurred at a lower rate compared with isolFNFs treated with any construct type and assocFNFs treated with multiple cannulated screws. The radiographic "shelf sign" was found as a positive prognostic sign in more than half of assocFNFs and predicted a high rate of successful treatment. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Health Numeracy Is Associated With a Patient's Ability to Interpret Patient-Reported Outcome Measures Data.

BACKGROUND: Patient-reported outcome measures (PROMs) were originally developed as research tools; however, there is increasing interest in using PROMs to inform clinical care. Prior work has shown the benefits of implementing PROMs at the point of care, but a patient's health numeracy (their ability to understand and work with numbers) may affect their ability to interpret PROM results. MATERIALS AND METHODS: We recruited patients presenting to an outpatient orthopedic clinic. Forty-nine patients completed a survey that included demographic information, the short-form General Health Numeracy Test, and accuracy questions about four PROM displays (bar graph, table, line graph, pictograph) that indicated the same PROM results. RESULTS: Patients with higher health numeracy answered all display accuracy questions correctly (P=.016). Patients who preferred using the table were more likely to answer display accuracy questions incorrectly (odds ratio, 0.013, P=.024). The two most frequently preferred PROM formats were bar graphs and tables, and most patients preferred to learn about their PROM function scores via a combination of displays and verbal discussions. CONCLUSION: Patient health numeracy is associated with the ability to correctly interpret visual displays of PROMs. Implementation of PROMs at point of care currently does not account for health numeracy. Efforts to account for health numeracy when using PROMs at point of care may improve the efficacy of using PROMs to improve outcomes in orthopedic surgery. [Orthopedics. 202x;4x(x):xx-xx.].

Comparative transcriptomic analysis of soybean cyst nematode inbred populations non-adapted or adapted on soybean rhg1-a/Rhg4-mediated resistance.

Soybean cyst nematode (SCN, Heterodera glycines) is most effectively managed through planting resistant soybean cultivars, but the repeated use of the same resistance sources has led to a widespread emergence of virulent SCN populations that can overcome soybean resistance. Resistance to SCN HG type 0 (Race 3) in soybean cultivar Forrest is mediated by an epistatic interaction between the soybean resistance genes rhg1-a and Rhg4. We previously developed two SCN inbred populations by mass-selecting SCN HG type 0 (Race 3) on susceptible and resistant recombinant inbred lines, derived from a cross between Forrest and the SCN-susceptible cultivar Essex, which differ for Rhg4. To identify SCN genes potentially involved in overcoming rhg1-a/Rhg4-mediated resistance, we conducted RNA-sequencing on early parasitic juveniles of these two SCN inbred populations infecting their respective hosts, only to discover a handful of differentially expressed genes (DEGs). However, in a comparison to early parasitic juveniles of an avirulent SCN inbred population infecting a resistant host, we discovered 59 and 171 DEGs uniquely up- or down-regulated in virulent parasitic juveniles adapted on the resistant host. Interestingly, the proteins coded by these 59 DEGs included vitamin B-associated proteins (reduced folate carrier, biotin synthase, and thiamine transporter) and nematode effectors known to play roles in plant defense suppression, suggesting that virulent SCN may exert a heightened transcriptional response to cope with enhanced plant defenses and an altered nutritional status of a resistant soybean host.

Pain Self-Efficacy Can Improve During a Visit With an Orthopedic Surgeon.

BACKGROUND: Greater pain self-efficacy (PSE) is associated with reduced pain, fewer limitations, and increased quality of life after treatment for orthopedic conditions. The aims of this study were to (1) assess if PSE improves during a visit with an orthopedic surgeon and (2) identify modifiable visit factors that are associated with an increase in PSE. MATERIALS AND METHODS: We performed a prospective observational study of orthopedic clinic visits at a multispecialty clinic from February to May 2022. New patients who presented to one of six orthopedic surgeons were approached for the study. Patients who provided consent completed a pre-visit questionnaire including the Pain Self-Efficacy Questionnaire (PSEQ) and demographic questions. A trained research member recorded the five-item Observing Patient Involvement in Decision Making Instrument (OPTION-5) score, number of questions asked, and visit duration. Immediately after the visit, patients completed a post-visit questionnaire consisting of the PSEQ and Perceived Involvement in Care Scale (PICS). RESULTS: Of 132 patients enrolled, 61 (46%) had improved PSE after the orthopedic visit, with 38 (29%) having improvement above a clinically significant threshold. There were no significant differences between patients with increased PSE and those without increased PSE when comparing the PICS, OPTION-5, questions asked, or visit duration. CONCLUSION: Almost half of the patients had improvement in PSE during an orthopedic visit. The causal pathway to how to improve PSE and the durability of the improved PSE have implications in strategies to improve patient outcomes in orthopedic surgery, such as communication methods and shared decision-making. Future research can focus on studying different interventions that facilitate improving PSE. [Orthopedics. 2024;47(4):e197-e203.].

Association between operative duration and adverse outcomes after hip fracture surgery: A NSQIP matched cohort study.

BACKGROUND: Prolonged operative duration is an independent risk factor for surgical complications in numerous subspecialties. However, associations between adverse events and operative duration of hip fracture fixation in older adults have not been well-quantified. This study aims to determine if prolonged operative duration of hip fracture surgery is related to adverse outcomes. We hypothesized that patients with high operative durations experience greater rates of 30-day complications. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was retrospectively reviewed to identify older adults (55 years and above) who underwent hip fracture fixation between 2015-2019. Prolonged operative duration was defined as >75th percentile, and cases were matched using propensity scores based on demographic, surgical, and comorbidity factors. Univariate differences in adverse events (including readmission, reoperation, mortality, and organ-system complications) were analyzed. Multivariable mixed-effects logistic regression analyses were completed for statistically significant events. RESULTS: A total of 8827 case-control pairs were identified for comparison. Rates of superficial surgical site infection (SSI) (p= 0.022), any SSI (p= 0.032), and any complication (p < 0.001) were elevated in those with prolonged surgical duration in univariate analyses. In multivariable models, prolonged operative time was associated with superficial SSI (OR 1.50, p= 0.019), any SSI (OR 1.35; p= 0.029) and any complication (OR 1.58; p < 0.001). In subgroup analyses, all findings persisted for IMN with operative time associated with superficial SSI (OR 1.98, p= 0.012), any SSI (OR 1.71; p= 0.019), and any complication (OR 1.84; p < 0.001). Operative time was associated only with any complication for hemiarthroplasty/internal fixation and sliding hip screw (OR 1.27 and 1.89, respectively; p < 0.001). CONCLUSION: Our study demonstrates that duration of surgery is an independent risk factor for superficial SSI, any SSI, and any complication. Notably, our findings suggest that high operative durations may be most concerning for SSIs in IMN fixation, which is currently the most common choice for hip fracture fixation in the US. However, the rate of any complication is significantly elevated when surgical duration is prolonged, regardless of surgery type.

Outcomes of isolated medial tibial plateau fractures by fracture morphology.

PURPOSE: To identify a cohort of isolated medial tibial plateau fractures treated with surgical fixation and to categorize them by Moore and Wahlquist classifications in order to determine the rate of complications with each fracture morphology and the predictive value of each classification system. We hypothesized there would be high rates of neurovascular injury, compartment syndrome, and complications overall with a higher incidence of neurovascular injury in Moore type III rim avulsion fractures and Wahlquist type C fractures that enter the plateau lateral to the tibial spines. METHODS: Patients who presented to six Level I trauma centers between 2010 and 2021 who underwent surgical fixation for isolated medial tibial plateau fractures were retrospectively reviewed. Data including demographics, radiographs, complications, and functional outcomes were collected. RESULTS: One hundred and fifty isolated medial tibial plateau fractures were included. All patients were classified by the Wahlquist classification of medial tibial plateau fractures, and 139 patients were classifiable by the Moore classification of tibial plateau fracture-dislocations. Nine percent of fractures presented with neurovascular injury: 5 % with isolated vascular injury and 6 % with isolated nerve injury. There were no significant differences in neurovascular injury by fracture type (Wahlquist p = 0.16, Moore p = 0.33). Compartment syndrome developed in two patients (1.3 %). The average final range of motion was 0.8-122° with no difference by Wahlquist or Moore classifications (p = 0.11, p = 0.52). The overall complication rate was 32 % without differences by fracture morphology. The overall rate of return to the operating room (OR) was 25 %. CONCLUSIONS: Isolated medial tibial plateau fractures often represent fracture-dislocations of the knee and should receive a meticulous neurovascular exam on presentation with a high suspicion for neurovascular injury. No specific fracture pattern was found to be predictive of neurovascular injuries, complications, or final knee range of motion. Patients should be counseled pre-operatively regarding high rates of return to the OR after the index surgery.

Unresolved haemosporidia of the Australian skink, Egernia stokesii.

The Australian skink Egernia stokesii had been recognised as a host of two species of Plasmodium, Plasmodium mackerrasae and P. circularis; nevertheless, molecular data are available for only a single haemosporidian species of this host. Its sequences are labelled as "Plasmodium sp." or "Plasmodium mackerrasae", but morphological characteristics of this isolate are unavailable. Phylogenetic analyses of these sequences placed them into the clade of the genus Haemocystidium. In this study, blood samples of six E. stokesii were analysed by both, molecular and microscopic methods to clarify the haemosporidia of this lizard. Application of these approaches offered discordant results. Whereas sequence analysis clustered our isolates with lizard species of Haemocystidium, morphology of blood stages is more akin to Plasmodium than Haemocystidium. However, limited sampling, indistinguishable nuclei/merozoites and risk of possible hidden presence of mixed infection prevent reliable species identification of detected parasites or their description as new species of Haemocystidium.

Historic indications for fixation of posterior malleolus fractures- where did they come from and where are we now?

INTRODUCTION: The indications for reduction and fixation of the posterior malleolus component of rotational ankle fractures have been controversial for nearly a century. This study aims to identify the historical basis for surgical intervention and trace trends in management strategies over time. METHODS: In March 2023, a systematic review of full-text, English-language articles providing indications for surgical fixation of the posterior malleolus component of rotational ankle fractures was performed. Articles underwent title and abstract screening before undergoing full-text review. RESULTS: Historical indications for surgical fixation were size-dependent, with fractures comprising 25 % to 33 % of the plafond recommended for internal fixation. Modern studies suggest that nonoperative management of posterior malleolus fractures below this threshold results in residual malreduction of the articular surface, syndesmotic instability, and an increased need for independent fixation of the syndesmosis. CONCLUSIONS: Size-based indications for posterior malleolus fracture fixation are based on Level V evidence from small retrospective case series published nearly one century ago and should be retired. While the size of the posterior malleolus component cannot be ignored, additional factors like fracture morphology and location within the plafond should guide modern surgical indications. Contemporary studies indicate that reduction and fixation of small posterior malleolus fractures (comprising less than 25 % of the articular surface) are associated with improved articular reductions, tibiotalar contact pressures, syndesmotic stability with decreased need for independent fixation of the syndesmosis, and superior postoperative outcomes.

Outcomes of Patients with Preoperative Thrombocytosis After Hip Fracture Surgery.

INTRODUCTION: Low platelet counts have clinically relevant effects on patient outcomes after hip fracture surgery; however, the relationship between abnormally high platelet counts and postoperative outcomes in this population is unknown. METHODS: The ACS-NSQIP database was queried for patients who underwent hip fracture surgery between 2015 and 2019. Outcomes were compared between patients with normal platelet counts (150,000 to 450,000/µL) and thrombocytosis (>450,000/µL). RESULTS: Eighty-six thousand three hundred eleven hip fracture patients were identified, of which 1067 (1.2%) had preoperative thrombocytosis. Compared with patients with normal platelet counts, patients with preoperative thrombocytosis had increased rates of 30-day mortality (6.4% vs 4.5%, P = 0.004; OR 1.15 [95% CI 0.88 to 1.50], P = 0.322) as well as increased rates and odds of readmission (11.4% vs 7.8%, P < 0.001; OR 1.35 [95% CI 1.10 to 1.65], P = 0.004) and venous thromboembolic events (3.2% vs 1.7%, P < 0.001; OR 1.88 [95% CI 1.31 to 2.71], P < 0.001). CONCLUSIONS: Hip fracture patients with preoperative thrombocytosis had increased rates of early mortality as well as increased odds of venous thromboembolic events and readmission. A patient with thrombocytosis may benefit from close postoperative surveillance and careful follow-up. Future prospective studies are needed to verify causation and investigate how to mitigate adverse outcomes in hip fracture patients with preoperative thrombocytosis.

3D Topographical Scanning for the Detection of Osteoporosis.

Objectives: Osteoporosis is associated with greater risk of fracture, which can lead to increased morbidity and mortality. DEXA scans are often inaccessible for patients, leaving many cases of osteoporosis undetected. A portable 3D topographical scan offers an easily accessible and inexpensive potential adjunct screening tool. We hypothesized that 3D scanning of arm and calf circumference and volume would correlate with DEXA T-scores. Methods: 96 female patients were enrolled. Patients were consented and completed a topographical scan of bilateral arms and lower legs with a mobile 3D scanner for arm and calf circumference and volume in clinic. Patient charts were then retrospectively reviewed for DEXA T-scores. Results: Forearm DEXA T-score was positively correlated with arm circumference (r = 0.49, p<0.01), arm volume (r=0.62, p<0.01), and calf volume (r=0.47, p<0.01). Femoral neck DEXA T-score was positively correlated with calf circumference (r=0.36, p<0.01) and calf volume (r=0.36, p<0.01). Conclusions: Our results showed significant correlations between DEXA T-scores and topographical measurements from mobile device acquired 3D scans, although these were in the "moderate" range. Mobile device-based 3D scanning may hold promise as an adjunct screening tool for osteoporosis when DEXA scanning is not available or feasible for patients, although further studies are needed to elucidate the full potential of its clinical utility. At a minimum, identifying a patient as high risk may promote earlier diagnostic DEXA scanning.

Inaccurately Reported Statin Use Affects the Assessing of Lipid Profile Measures and Their Association with Coronary Artery Disease Risk.

BACKGROUND: Lipid profiling is central for coronary artery disease (CAD) risk assessment. Nonadherence or unreported use of lipid-lowering drugs, particularly statins, can significantly complicate the association between lipid profile measures and CAD clinical outcomes. By combining medication history evaluation with statin analysis in plasma, we determined the effects of inaccurately reported statin use on lipid profile measures and their association with CAD risk. METHODS: We compared medication history of statin use with statin concentration measurements, by liquid chromatography-tandem mass spectrometry, in 690 participants undergoing coronary angiography (63 ± 11 years of age). Nominal logistic regression was employed to model CAD diagnosis with statin measurements, phenotypic, and lipid profile characteristics. RESULTS: Medication history of statin use was confirmed by statin assay for 81% of the patients. Surprisingly, statins were detected in 46% of patients without statin use records. Nonreported statin use was disproportionately higher among older participants. Stratifying samples by statin history resulted in underestimated LDL-lipid measures. Apolipoprotein B concentrations had a significant inverse CAD association, which became nonsignificant upon re-stratification using the statin assay data. CONCLUSIONS: Our study uncovered prominent discrepancies between medication records and actual statin use measured by mass spectrometry. We showed that inaccurate statin use assessments may lead to overestimation and underestimation of LDL levels in statin user and nonuser categories, exaggerating the reverse epidemiology association between LDL levels and CAD diagnosis. Combining medication history and quantitative statin assay data can significantly improve the design, analysis, and interpretation of clinical and epidemiological studies.

The use of hinged elbow orthosis following surgical management of terrible triad injuries of the elbow.

PURPOSE: To determine outcomes following surgical management of terrible triad injuries in patients treated with and without a hinged elbow orthosis (HEO) in the post-operative setting. METHODS: This study was a retrospective review of 41 patients who underwent surgical treatment of terrible triad injuries including radial head fracture, coronoid fracture, and ulnohumeral dislocation between 2008 and 2023 with at least 10-week follow-up. RESULTS: Nineteen patients were treated post-operatively without HEO, and 22 patients were treated with HEO. There were no differences in range of motion (ROM) between patients treated with and without HEO in final flexion-extension arc (118.4° no HEO, 114.6° HEO, p = 0.59) or pronation-supination arc (147.8° no HEO, 141.4° HEO, p = 0.27). Five patients treated without HEO and one patient treated with HEO returned to the operating room for stiffness (26%, 5%, p = 0.08). QuickDASH scores were similar between groups (p = 0.69). CONCLUSIONS: This study found no difference in post-operative ROM, complications, or QuickDASH scores in patients treated post-operatively with or without HEO. Based on these results, we cannot determine whether the use of HEO adds additional stability to the elbow while initiating ROM exercises post-operatively.

Range of motion measurements do not correlate with patient reported outcome measures in the early post-operative period following ankle fracture.

BACKGROUND: Early mobilization following ankle fracture open reduction and internal fixation (ORIF) improves long-term patient functionality. Because of this, numerous resources have been spent to increase patient adherence to post-operative mobilization, with range of motion (ROM) measurements generally considered an important outcome in patient recovery. In this study we investigated how ankle ROM correlates to patient function, self-sufficiency in performing activities of daily living (ADLs), and pain in the early post-operative period. METHODS: This was a prospective, observational study on patients undergoing ORIF of ankle fractures. We collected patient reported outcome measures (PROMs) and ROM measurements at the 2-week, 6-week, 12-week, and 6 month post-operative visit. We collected three PROMs: pain intensity (VAS), pain self-efficacy questionnaire (PSEQ-2), and foot and ankle ability measurement (FAAM). ROM of the ankle was measured by goniometer. ANOVA and post-hoc Tukey tests were used to examine statistical differences in PROMs over time. Pearson correlation tests were used to examine the association between ROM and PROMs. RESULTS: One-hundred and twenty-three participants enrolled in this study in the perioperative period. Pain intensity was higher at enrollment compared to week 6 (post-hoc p = 0.006), after which pain intensity did not differ significantly. FAAM scores for activities or daily living (ADL) were increased at all study visits compared to enrollment (post-hoc p < 0.001). FAAM-Sports scores were higher compared to enrollment at the week 12 and 6 month visits (post-hoc p < 0.001). No significant improvements in goniometer measurements were noted across any timepoints. There were no significant correlations between ROM and PROMs at any of the study visits. CONCLUSION: In our cohort of patients, there was no correlation between ROM and patient pain, self-efficacy or functionality in the early post-operative period following ankle ORIF. The lack of correlation between PROMs and ROM indicates that ROM may be both a poor indicator of patient improvement for physicians to guide post-operative treatment as well as a poor motivator for patient adherence to post-operative exercises. In the future, it is important to study reliable outcome measures in early recovery that can be utilized to track patient recovery from ankle ORIF.