Operative Management of Proximal Humerus Nonunions in Adults: A Systematic Review.

OBJECTIVES: To characterize the literature on operative interventions for proximal humerus nonunions in adults. Second, to identify prognostic factors associated with outcomes for locked plate open reduction and internal fixation (ORIF). DATA SOURCES: PubMed, EMBASE, MEDLINE, Scopus, and Cochrane databases were searched for articles from 1990 to 2020. STUDY SELECTION: Studies reporting outcomes of proximal humerus nonunions managed with ORIF, hemiarthroplasty (HA), total shoulder arthroplasty (TSA), or reverse TSA (RTSA) were included. Studies failing to stratify outcomes by treatment or fracture sequelae were excluded. DATA EXTRACTION: Two authors independently extracted data and appraised study quality using MINORS score. DATA SYNTHESIS: Descriptive statistics were reported. Outcomes for ORIF and arthroplasty groups were not compared due to differing patient populations. CONCLUSIONS: Thirty-seven articles were included, representing 508 patients (246 ORIF, 137 HA/TSA, and 125 RTSA). Patients managed by ORIF were younger with simpler fracture patterns than those managed by arthroplasty. Regarding ORIF, locked plates achieved highest union rates (97.0%), but clinical outcomes were comparable with all plate fixation constructs [forward flexion (FF): 123-144°; external rotation: 42-46°; Constant score: 75-84]. Complication and reoperation rates for ORIF were 26.0% and 14.6%, respectively. Furthermore, subgroup analysis of locked plate ORIF demonstrated shorter consolidation time with initial conservative fracture management (4.3 vs. 6.0 months) and autograft use (3.9 vs. 5.5 months). With arthroplasty, RTSA demonstrated greater forward flexion (109.4° vs. 97.2°) but less external rotation (16.5° vs. 36.8°) than HA/TSA. Complication and reoperation rates were 18.2% and 10.9% for HA/TSA and 21.6% and 14.4% for RTSA, respectively. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for heterotopic ossification in operatively treated proximal humeral fractures.

AIMS: Heterotopic ossification (HO) is a potentially devastating complication of the surgical treatment of a proximal humeral fracture. The literature on the rate and risk factors for the development of HO under these circumstances is lacking. The aim of this study was to determine the incidence and risk factors for the development of HO in these patients. METHODS: A retrospective analysis of 170 patients who underwent operative treatment for a proximal humeral fracture between 2005 and 2016, in a single institution, was undertaken. The mean follow-up was 18.2 months (1.5 to 140). The presence of HO was identified on follow-up radiographs. RESULTS: The incidence of HO was 15% (n = 26). Our multivariate model revealed that male sex (odds ratio (OR) 3.57, 95% confidence interval (CI) 1.30 to 9.80 compared to female) and dislocation as the initial injury (OR 5.01, 95% CI 1.31 to 19.22) were significantly associated with the formation of HO (p < 0.05) while no significant associations were seen for the age of the patient, the characteristics of the injury, or the type of operative treatment. CONCLUSION: This retrospective radiological study is the first to investigate the association between the method of surgical treatment for a proximal humeral fracture and the formation of HO postoperatively. We found that male sex and dislocation as the initial injury were risk factors for HO formation, whereas the method of surgical treatment, the age of the patient, and the pattern of the fracture were not predictive of HO formation. While additional studies are needed, these findings can help to identify those at an increased risk for HO formation under these circumstances. Cite this article: Bone Joint J 2020;102-B(4):539-544.

Soft tissue resurfacing for glenohumeral arthritis: a systematic review.

BACKGROUND: Severe glenohumeral arthritis in the young/active patient remains challenging. Historically, glenohumeral arthrodesis was recommended with limited return of function. Total shoulder arthroplasty has shown increasing survivorship at 15 years; however it is still not ideal for young patients. Biologic resurfacing of the glenoid with humeral head replacement has shown promising results. METHODS: The PubMed and Embase databases were queried for studies evaluating outcomes of glenoid biologic resurfacing with autograft or allograft. Two independent reviewers performed a systematic review according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. RESULTS: Eleven studies (268 shoulders, 264 patients) were included. Minimum follow-up was 24 months in all but one study; patient age ranged from 14 to 75 years. Glenoid grafts used included 44.3% lateral meniscus allografts, 25.4% human acellular dermal matrix, 14.2% Achilles tendon allografts, 11.6% shoulder joint capsules, and 4.5% fascia lata autografts. Studies reported significantly improved American Shoulder and Elbow Surgeons, Visual Analog Scale, and Simple Shoulder Test scores postoperatively; 43.3% were failures (Neer's evaluation of unsatisfactory or requiring revision). Infection occurred in 12/235. CONCLUSIONS: Biologic resurfacing of the glenoid with a metallic humeral component can provide a significant improvement in pain, motion, and standardized outcomes scores in the well-indicated situation. Appropriate counseling is required with an appreciated complication rate of over 36% and a revision rate of 34%.

Effectiveness of intravenous acetaminophen for postoperative pain management in shoulder arthroplasties: A population-based study.

BACKGROUND: Intravenous acetaminophen (IV APAP) is an option in multimodal postoperative analgesia. Prior trials focus on hip and knee arthroplasties, whereas large-scale data on utilization and effectiveness in shoulder arthroplasties are lacking. METHODS: Data on 67,494 (452 hospitals) partial/total shoulder arthroplasties were extracted from the Premier claims database (2011-2016). Patients were categorized by receipt and dosage of IV APAP. Multilevel models measured associations between IV APAP and opioid utilization (in oral morphine equivalents), length/cost of stay and opioid-related complications. Effect estimates (adjusted % change) with 95% confidence intervals (CIs) are reported. RESULTS: IV APAP was used in 17.7% (n = 11,949) of patients with an increasing utilization trend. Most patients received only one dose on the day of surgery (69.5%; n = 8308). When adjusting for relevant covariates, IV APAP was not associated with meaningful effects on outcomes. Specifically, its use (versus no use) was not associated with decreased (but rather somewhat increased) opioid utilization: + 5.4% (CI 3.6-7.1%; P < 0.05). CONCLUSION: In this first large-scale study that assesses IV APAP in shoulder arthroplasties, IV APAP use was not associated with decreased opioid utilization or the length/cost of stay. These results do not support routine use of IV APAP in this cohort, especially given its high cost. THE TRANSLATIONAL POTENTIAL FOR THIS ARTICLE: Multimodal pain control to assist in reducing the opioid pain medications are seen as a route to improved postoperative patient outcomes, better pain control and expedited hospital discharge. Acetaminophen plays a significant role in these protocols in many institutions, but it is not established if this expensive IV formulation is superior to the oral formulation. This study evaluates the use and effectiveness of IV acetaminophen following shoulder arthroplasty at a large number of institutions.

Ambiguous Nomenclature in Musculoskeletal Magnetic Resonance Imaging.

INTRODUCTION: Medical vocabulary that conveys different meanings to different groups of readers can lead to confusion and potential misinterpretation of diagnoses. This article reviews words used by radiologists that convey information to the orthopedic surgeon and patient that is different from what the radiologist intended. These terms include meniscal tears, ligament sprains, partial tendon tears, bone bruises, bone contusions, articular cartilage injury, disc bulges, disc herniations, and joint subluxation. These words can, for example, suggest a traumatic etiology when in fact the condition is atraumatic, and they can imply a surgical treatment where none is indicated. This problem is further magnified in the arena of personal injury litigation. MATERIALS AND METHODS: The terms tear, bruise, contusion, injury, sprain, bulge, herniation, and subluxation are defined and analyzed for their ambiguous use, i.e., their actual versus intended meaning or other interpretation. RESULTS: Abnormalities and variations observed on musculoskeletal magnetic resonance (MR) images are often multi-factorial and may not be the source of any given patient's symptoms. The same MR image findings can have a congenital, traumatic, or degenerative source. CONCLUSIONS: Radiology vocabulary that invokes a singular traumatic event as a cause of an MRI finding can significantly mislead patients (as well as judges and juries). We propose that some terms be either avoided entirely when the findings are of uncertain etiology. At the very least, the various meanings of the terms need to be spelled out. Greater cooperation between orthopedic surgeons and radiologists on this matter would be beneficial to patient care.

Utilization and Real-world Effectiveness of Tranexamic Use in Shoulder Arthroplasty: A Population-based Study.

INTRODUCTION: Tranexamic acid (TXA) is increasingly used to reduce blood loss in lower extremity arthroplasty, but limited data exist for its effectiveness in patients undergoing shoulder arthroplasty. We aimed to use national data to assess the frequency of use and effectiveness of TXA in patients undergoing shoulder arthroplasty. METHODS: Using national claims data from patients undergoing shoulder arthroplasty (Premier Healthcare; 2010 to 2016; n = 82,512; 429 hospitals), we categorized patients according to whether they received perioperative TXA. Multilevel multivariable regression models measured associations between TXA and blood transfusion risk, combined complications (including thromboembolic events, acute renal failure, cerebral infarction, and acute myocardial infarction), and length and cost of hospitalization. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. RESULTS: Overall, TXA was used in 12.8% (n = 10,582) of patients with a strong increasing trend. After adjustment for relevant covariates, TXA use (compared with no TXA use) was associated with a 36% decrease in transfusion risk (OR, 0.64; 95% CI, 0.52 to 0.77; P < 0.05) and a 35% decreased risk for combined complications (OR, 0.65; 95% CI, 0.50 to 0.83; P < 0.05). Moreover, TXA use was associated with 6.2% shorter hospital stay (95% CI, -8.0% to -4.4%; P < 0.05), whereas no difference was observed with the cost of hospitalization. CONCLUSION: In this first large-scale study assessing TXA use and effectiveness in patients undergoing shoulder arthroplasty, we found that although TXA utilization is still low, it is associated with a marked decrease in transfusion risk with no increases in complication risk. Effects on the length and cost of hospitalization appeared minor. Future studies should assess whether higher volumes of TXA utilization would translate into more gains on the length and cost of hospitalization. LEVEL OF EVIDENCE: Level III.

No safe zone: The anatomy of the saphenous nerve and its posteromedial branches.

BACKGROUND: Following a case of medial meniscal repair via an inside-out repair, a patient developed acute postoperative electric shock-like paresthesias of the proximal medial calf with any knee flexion beyond 80°. Open saphenous nerve exploration revealed entrapment by suture material of an unnamed branch off the sartorial branch of the saphenous nerve. Symptoms resolved immediately with release. The objective of the study was to perform a cadaveric study to examine the existence and frequency of these previously under-reported branches of the sartorial branch of the saphenous nerve. METHODS: In 16 knees from eight fresh, matched whole cadavers, the medial structures of the knee were exposed, reproducible anatomical structures were identified, and previously under-described posteromedial branches of the sartorial nerve were identified and measured in relation to surrounding structures and the joint line. RESULTS: The saphenous nerve, its sartorial and infrapatellar branches, and its posteromedial branches were identified in all specimens. The sartorial nerve divided from the saphenous nerve an average of 4.8 cm proximal to the medial femoral epicondyle. Between one and four further posteromedial branches off the sartorial nerve were identified. These branches formed at a range of 5.3 cm proximal to 3.0 cm distal to the joint line. CONCLUSIONS: This cadaveric study establishes the consistent presence of a posteromedial branch off the sartorial nerve. It was consistently located near the posteromedial joint line. These branches are at risk for injury during medial meniscus repairs due to entrapment by suture materials, or during other surgical procedures near the posteromedial aspect of the knee.

Acromial spine fracture after reverse total shoulder arthroplasty: a systematic review.

BACKGROUND: Reverse total shoulder arthroplasty (RSA) accounts for nearly one-third of shoulder arthroplasty utilization nationally. The complication rate has increased concurrently. Consensus is lacking regarding the incidence, etiology, and treatment of acromial or scapular spine fractures after RSA. The purpose of our study was to perform a systematic review of the literature to analyze the occurrence and outcomes of this complication. METHODS: The MEDLINE, Embase, Google Scholar, and Cochrane databases were queried in late 2017 for combinations of the words "acromial," "fracture," "reverse," "shoulder," and "arthroplasty." We included all studies that contained a clearly defined performance of RSA, acromial fracture(s) noted, and treatment (if any) and outcomes of treatment. The initial search yielded 50 studies; 32 met the inclusion criteria. RESULTS: Among 3838 RSAs, 159 acromial fractures were reported, for an overall incidence of 4.14%; the mean time to diagnosis from surgery was 9 months (range, 1.3-24 months). Treatments included nonoperative treatment in a sling or abduction brace in 139 cases and open reduction-internal fixation in 20. Regardless of treatment, patients reported inferior function after fracture compared with initially after RSA. Forward flexion was 95° (range, 30°-110°), abduction was 76° (range, 30°-180°), the Constant score was 63 (range, 59-67.5), and the American Shoulder and Elbow Surgeons score was 57 (range, 7-83); all values were reduced compared with patients without fractures. CONCLUSION: This study suggests the occurrence of acromial fractures after RSA is a common event, with a rate of over 4%. These fractures correlate with worse postoperative outcomes regardless of treatment method; open reduction-internal fixation was not shown to be clinically superior despite a limited complication rate. Additional high-quality studies addressing acromial spine fracture after RSA are needed.

Episode-based cost reduction for endovascular aneurysm repair.

OBJECTIVE: Effective strategies to reduce costs associated with endovascular aneurysm repair (EVAR) remain elusive for many medical centers. In this study, targeted interventions to reduce inpatient EVAR costs were identified and implemented. METHODS: From June 2015 to February 2016, we analyzed the EVAR practice at a high-volume academic medical center to identify, to rank, and ultimately to reduce procedure-related costs. In this analysis, per-patient direct costs to the hospital were compared before (September 2013-May 2015) and after (March 2016-January 2017) interventions were implemented. Improvement efforts concentrated on three categories that accounted for a majority of costs: implants, rooming costs, and computed tomography scans performed during the index hospitalization. RESULTS: Costs were compared between 141 EVAR procedures before implementation (PRE period) and 47 EVAR procedures after implementation (POST period). Based on data obtained through the Society for Vascular Surgery EVAR Cost Demonstration Project, it was determined that implantable device costs were higher than those at peer institutions. New purchasing strategies were implemented, resulting in a 30.8% decrease in per-case device costs between the PRE and POST periods. Care pathways were modified to reduce use of and costs for computed tomography scans obtained during the index hospitalization. Compared with baseline, per-case imaging costs decreased by 92.9% (P < .001), including a 99.0% (P = .001) reduction in postprocessing costs. Care pathways were also implemented to reduce preprocedural rooming for patients traveling long distances the day before surgery, resulting in a 50% decrease in utilization rate (35.4% PRE to 17.0% POST; P = .021), without having a significant impact on median postprocedural length of stay (PRE, 2 days [interquartile range, 1-11 days]; POST, 2 days [1-7 days]; P = .185). Medication costs also decreased by 38.2% (P < .001) as a hospital-wide effort. CONCLUSIONS: Excessive costs associated with EVAR threaten the sustainability of these procedures in health care organizations. Targeted cost reduction efforts can effectively reduce expenses without compromising quality or limiting patients' access.

Approach to the Patient with Disproportionate Pain.

Faced with a patient who presents with unexplained disproportionate pain, a surgeon may be tempted to diagnose a low pain threshold, malingering, poor coping, anxiety, or other emotional condition. However, a variety of conditions must be ruled out before the orthopedist can prescribe watchful waiting. Computed tomography and magnetic resonance imaging can detect occult fractures, acute spinal conditions or vascular occlusions, but early on are inadequate to diagnose a compartment syndrome, necrotizing fasciitis, or reflex sympathetic dystrophy (RSD). These diagnoses underpin a pain-out-of-proportion situation whereby the patient presents with disproportionate pain following a sometimes minor trauma with normal imaging studies and otherwise nonspecific presentations. Though these conditions are well described in the literature, investigations of malpractice data reveal a non-negligible prevalence of missed diagnoses for each of these entities. Determining that a patient exhibits otherwise unexplained pain-out-of-proportion situation is the first step in making a timely diagnosis.

Anatomic landmarks for arthroscopic suprapectoral biceps tenodesis: a cadaveric study.

BACKGROUND: Biceps tenodesis reduces the incidence of Popeye deformity occurring with tenotomy, but pain may occur with tenodesis superior to or within the bicipital groove. Arthroscopic suprapectoral tenodesis is an attractive alternative. The purpose of this study was to establish landmarks for arthroscopic suprapectoral tenodesis and determine the appropriate fixation point to optimize muscle tension. METHODS: Twelve fresh cadaveric shoulders were dissected. Urethane polymer was injected into the axillary artery. The position of the anterior branch of the axillary nerve was marked. The transverse humeral ligament was split, exposing the biceps (long head of the biceps [LHB]) from its origin to the pectoralis major tendon (PMT). The intra-articular portion was released. Measurements were taken from the proximal tendon to described landmarks. RESULTS: The mean length of the intra-articular LHB was 2.53 cm (range, 1.72-3.55 cm). The mean distance from the LHB origin to the inferior lesser tuberosity (LT) was 5.58 cm (range, 4.02-6.87 cm), and that to the superior border of the PMT was 8.46 cm (range, 6.46-10.78 cm). The suprapectoral tenodesis zone (inferior LT to superior PMT) was 2.96 cm (range, 1.54-4.40 cm). In all specimens, a branch of the anterior humeral circumflex arose medial to the LHB and distal to the LT and crossed the suprapectoral zone from medial to lateral at 1.49 ± 0.42 cm proximal to the PMT, approximately at the level of the axillary nerve. The musculocutaneous nerve was on average 3.06 cm (range, 1.86-3.76 cm) from the tenodesis zone. CONCLUSION: A branch of the anterior humeral circumflex is a reliable landmark for identifying the mid-suprapectoral zone. The distance from the proximal LHB tendon to this crossing vessel averaged 6.32 cm in female specimens and 8.28 cm in male specimens. These findings allow appropriate tensioning of the LHB during arthroscopic suprapectoral tenodesis.

Asynchronous slipped capital femoral epiphysis in a patient with a seizure disorder: case report and review of the literature.

Debate remains about the appropriate treatment of the asymptomatic side following treatment of a unilateral slipped capital femoral epiphysis (SCFE). A 12-year-old boy with a seizure disorder presented with an unstable SCFE on the left hip following a seizure. He underwent percutaneous pinning of the left only. At 8 months postoperatively, he returned with an unstable slip of the right hip, again following a seizure. No literature discussing the treatment of patients with risk of SCFE and seizure disorders was identified. Further study may identify an increased incidence of contralateral slip following an initial slip in this population. If a greater risk exists, contralateral prophylactic fixation at time of index surgery may be indicated.

Return to Play in Elite Contact Athletes After Anterior Cervical Discectomy and Fusion: A Meta-Analysis.

STUDY DESIGN: Systematic literature review and meta-analysis of studies published in English language. OBJECTIVE: Return to play after anterior cervical discectomy and fusion (ACDF) in contact athletes remains a controversial topic with no consensus opinion in the literature. Additional information is needed to properly advise and treat this population of patients. This study is a meta-analysis assessing return to competitive contact sports after undergoing an ACDF. METHODS: A literature search of Medline, Embase, and Cochrane Reviews was performed to identify investigations reporting return to play following ACDF in professional contact athletes. The pooled results were performed by calculating the effect size based on the logic event rate. Studies were weighted by the inverse of the variance, which included both within and between-study error. Confidence intervals (CIs) were reported at 95%. Heterogeneity was assessed using the Q statistic and I2. Sensitivity analysis and publication bias calculations were performed. RESULTS: The initial literature search resulted in 166 articles, of which 5 were determined relevant. Overall, return to play data was provided for 48 patients. The pooled clinical success rate for return to play was 73.5% (CI = 56.7%, 85.8%). The logit event rate was calculated to be 1.036 (CI = 0.270, 1.802), which was statistically significant (P = .008). The studies included in this meta-analysis demonstrated minimal heterogeneity with Q value of 4.038 and I2 value of 0.956. CONCLUSIONS: Elite contact athletes return to competition 73.5% of the time after undergoing ACDF. As this is the first study to pool results from existing studies, it provides strong evidence to guide decision making and expectations in this patient population.

Lawsuits After Primary and Revision Total Knee Arthroplasty: A Malpractice Claims Analysis.

INTRODUCTION: As the number of total knee arthroplasties (TKAs) increases, the number of associated complications will also increase. Our goal with this study was to identify common causes of and financial trends relating to malpractice claims filed after TKA. METHODS: We analyzed malpractice claims filed for alleged neglectful primary and revision TKA surgeries performed between 1982 and 2012 by orthopaedic surgeons insured by a large New York state malpractice carrier. RESULTS: We identified 69 primary and 8 revision TKAs in the malpractice carrier's database. All cases were performed between 1982 and 2012; all claims were closed between 1989-2015. The most frequent factor leading to lawsuits for primary TKA was chronic pain or dissatisfaction in 12 cases, followed by nerve palsy in 8, postoperative in-hospital falls in 5, and deep vein thrombosis or pulmonary embolism in 3. Medical complications included acute respiratory distress syndrome, cardiac arrest, and decubitus ulcers. Contracture was most common after revision TKA (three of eight cases). Mean indemnity was $325,369, and the largest single settlement was $2.42 million. The average expense relating to the defense of these cases was $66,365. CONCLUSIONS: Orthopaedic surgeons should continue to focus attention on prevention of complications and on preoperative patient education. Preoperative counseling regarding the risks of incomplete pain relief could reduce substantially the number of suits relating to primary TKAs.

Atraumatic segmental atypical femur fracture secondary to bisphosphonate use: A case report.

Atypical femur fractures as a result of long term bisphosphonate use are characterized by several unique radiographic features. We describe an atypical femur fracture treated by cephalomedullary nail with a previously undescribed segmental fracture pattern. Other than 1.5 years of bisphosphonate use the patient did not have any other risk factors known to cause atypical femur fractures. Judicious bisphosphonate use as well as increased awareness of the associated complications may help reduce the rate of bisphosphonate associated atypical femur fractures.

Lawsuits After Primary and Revision Total Hip Arthroplasties: A Malpractice Claims Analysis.

BACKGROUND: As the prevalence of total hip arthroplasty (THA) expands, so too will complications and patient dissatisfaction. The goal of this study was to identify the common etiologies of malpractice suits and costs of claims after primary and revision THAs. METHODS: Analysis of 115 malpractice claims filed for alleged neglectful primary and revision THA surgeries by orthopedic surgeons insured by a large New York state malpractice carrier between 1983 and 2011. RESULTS: The incidence of malpractice claims filed for negligent THA procedures is only 0.15% per year in our population. In primary cases, nerve injury ("foot drop") was the most frequent allegation with 27 claims. Negligent surgery causing dislocation was alleged in 18 and leg length discrepancy in 14. Medical complications were also reported, including 3 thromboembolic events and 6 deaths. In revision cases, dislocation and infection were the most common source of suits. The average indemnity payment was $386,153 and the largest single settlement was $4.1 million for an arterial injury resulting in amputation after a primary hip replacement. The average litigation cost to the insurer was $61,833. CONCLUSION: Nerve injury, dislocation, and leg length discrepancy are the most common reason for malpractice after primary THA. Orthopedic surgeons should continue to focus on minimizing the occurrence of these complications while adequately incorporating details about the risks and limitations of surgery into their preoperative education.

Genomewide Association Study of Alcohol Dependence Identifies Risk Loci Altering Ethanol-Response Behaviors in Model Organisms.

BACKGROUND: Alcohol dependence (AD) shows evidence for genetic liability, but genes influencing risk remain largely unidentified. METHODS: We conducted a genomewide association study in 706 related AD cases and 1,748 unscreened population controls from Ireland. We sought replication in 15,496 samples of European descent. We used model organisms (MOs) to assess the role of orthologous genes in ethanol (EtOH)-response behaviors. We tested 1 primate-specific gene for expression differences in case/control postmortem brain tissue. RESULTS: We detected significant association in COL6A3 and suggestive association in 2 previously implicated loci, KLF12 and RYR3. None of these signals are significant in replication. A suggestive signal in the long noncoding RNA LOC339975 is significant in case:control meta-analysis, but not in a population sample. Knockdown of a COL6A3 ortholog in Caenorhabditis elegans reduced EtOH sensitivity. Col6a3 expression correlated with handling-induced convulsions in mice. Loss of function of the KLF12 ortholog in C. elegans impaired development of acute functional tolerance (AFT). Klf12 expression correlated with locomotor activation following EtOH injection in mice. Loss of function of the RYR3 ortholog reduced EtOH sensitivity in C. elegans and rapid tolerance in Drosophila. The ryanodine receptor antagonist dantrolene reduced motivation to self-administer EtOH in rats. Expression of LOC339975 does not differ between cases and controls but is reduced in carriers of the associated rs11726136 allele in nucleus accumbens (NAc). CONCLUSIONS: We detect association between AD and COL6A3, KLF12, RYR3, and LOC339975. Despite nonreplication of COL6A3, KLF12, and RYR3 signals, orthologs of these genes influence behavioral response to EtOH in MOs, suggesting potential involvement in human EtOH response and AD liability. The associated LOC339975 allele may influence gene expression in human NAc. Although the functions of long noncoding RNAs are poorly understood, there is mounting evidence implicating these genes in multiple brain functions and disorders.

Increased risk of 30-day postoperative complications for diabetic patients following open reduction-internal fixation of proximal humerus fractures: an analysis of 1391 patients from the American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: Prior database studies have shown that complication rates following surgical treatment of proximal humerus fractures are low. However, diabetes has been shown across orthopedics to have significantly increased risks of postoperative complications. The purpose of our study was to identify complications for which diabetic patients are at increased risk following operative treatment of proximal humerus fractures. METHODS: The National Surgical Quality Improvement Program database from 2005 to 2014 identified patients >18 years undergoing open reduction-internal fixation for proximal humerus fractures. Patients with incomplete perioperative data were excluded. Patients with non-insulin-dependent diabetes mellitus (NIDDM) and insulin-dependent diabetes mellitus (IDDM) were compared with nondiabetic patients using multivariate logistic regression analysis. Odds ratio (OR) was calculated with a 95% confidence interval, and the significance level was held at P < .05. RESULTS: There were 1391 patients identified; 1147 (82%) were not diabetic, 91 (7%) had IDDM, and 153 (11%) had NIDDM. Of these, 39.68% (550) were obese (body mass index >30.0). Hypertension, dyspnea, and chronic obstructive pulmonary disease were the most frequent concurrent patient factors in diabetic patients. Postoperatively, patients with diabetes had a statistically significant higher risk of pneumonia (OR, 217.80; P = .002) and length of stay >4 days (OR, 2.05; P = .010). Among diabetics, non-insulin-dependent diabetics had a greater risk of sepsis (OR, 25.84; P = .022) and pneumonia (OR, 12.19; P = .013) than insulin-dependent diabetics. CONCLUSION: Both NIDDM and IDDM were associated with a number of adverse postoperative events. Importantly, NIDDM was found to be an independent risk factor for postoperative sepsis and pneumonia, whereas IDDM was identified as an independent risk factor for pneumonia and prolonged length of stay (≥4 days).

The Effect of Obesity on the Improvement in Health State Outcomes following Minimally Invasive Transforaminal Interbody Fusion.

Study Design Observational study. Objective Studies have shown a correlation between obesity and lumbar spine pathology, but also that obese patients have higher rates of complication following lumbar spine surgery. It is unknown if obese patients have clinical gains following lumbar spine surgery comparable to the gain of normal-weight patients. This study investigated the correlation of obesity and the delta change in outcomes in a single surgeon's cohort of normal-weight and obese patients undergoing minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF). Methods A retrospective review was performed of a single surgeon's patients at an academic medical center who underwent MIS TLIF between July 2011 and December 2013. Statistical analyses included independent sample t test for continuous variables, Fisher exact test for categorical data, and repeated measures two-way analysis of variance to assess the interaction between obesity status and the change in Short-Form Health Survey 12 (SF-12) results. Results Thirty-eight patients from a single institution were reviewed, and 19 had a body mass index greater than 30. The nonobese and obese postoperative SF-12 mental composite scores (MCS; 52.70 ± 2.50 versus 52.16 ± 1.91; p = 0.87) and physical composite scores (PCS; 45.56 ± 2.72 versus 41.03 ± 2.65; p = 0.24) did not show any significant differences. There was no significant interaction between obesity and change in SF-12 MCS (F [1, 36] = 0.96, p = 0.33) or SF-12 PCS (F [1, 36] = 0.74, p = 0.40) between the pre- and postoperative scores. There was a significant effect of obesity on SF-12 PCS scores (F [1, 36] = 7.15, p = 0.01). Conclusions Patients undergoing MIS TLIF sustain meaningful and significant gains in SF-12 MCS and PCS that is not impacted by their obesity status.

Outerbridge Grade IV Cartilage Lesions in the Hip Identified at Arthroscopy.

PURPOSE: To determine factors associated with grade IV cartilage defects in the hip in patients undergoing hip arthroscopy with joint pain. METHODS: Data from consecutive patients who underwent hip arthroscopy performed by a single surgeon over a period of 4 years were included in this study. The study group included 1,097 patients (491 women and 606 men; mean age, 37 years) who underwent hip arthroscopy for pain, had no prior hip surgery, and were aged 18 years or older. Preoperative radiographs, patient demographic characteristics, and operative details were used to identify risk factors for cartilage defects. RESULTS: Grade IV chondral defects were present in 308 of 1,097 hips (28%). Isolated chondral lesions were more frequently observed on the acetabulum (76%) than on the femoral head (24%). Defects of the acetabulum were more commonly anterosuperior (94.7%) and less commonly posterolateral (5.3%). Patients with less than 2 mm of joint space on preoperative radiographs were 8 times more likely to have a grade IV lesion than those with more than 2 mm. Men were more likely than women to have grade IV lesions (35% v 19%, P = .0001); patients with grade IV lesions were older than those without (42 years v 34 years, P = .0001). Hips with grade IV lesions had significantly higher alpha angles than those without (74° v 70°, P = .0001). Patients with grade IV defects reported a longer duration of symptoms than those without (37 months v 27 months, P = .007). Independent risk factors for the presence of grade IV chondral defects were less than 2 mm of joint space, male gender, increasing age, larger alpha angle, and longer duration of symptoms. CONCLUSIONS: Grade IV chondral defects in patients undergoing hip arthroscopy were associated with decreased joint space, increased time from symptom onset to arthroscopy, male gender, and larger alpha angles associated with femoroacetabular impingement. LEVEL OF EVIDENCE: Level IV, prognostic case series.