Trends in inpatient versus outpatient upper extremity fracture surgery from 2008 to 2021 and their implications for equitable access: a retrospective cohort study.

PURPOSE: The aim of this study is to describe trends in inpatient and outpatient upper extremity fracture surgery between 2008 and 2021, along with identifying patient factors (age, sex, race, socioeconomic status) associated with outpatient surgery. METHODS: Retrospectively, 12,593 adult patients who underwent upper extremity fracture repair from 2008 to 2021 at one of five urban hospitals in the Northeastern USA were identified. Using Distressed Communities Index (DCI), patients were divided into five quintiles based on their level of socioeconomic distress. Multivariable logistic regression was performed on patients from 2008 to 2019 to identify independent factors associated with outpatient management. RESULTS: From 2008 to 2019, outpatient procedures saw an average increase of 31%. The largest increases in the outpatient management were seen in humerus (132%) and forearm fractures (127%). Carpal and hand surgeries had the lowest percent increase of 8.1%. Clavicle and wrist fractures were independently associated with outpatient management. Older age, male sex, higher Elixhauser comorbidity index, DCI scores in the 4th or 5th quintile, and fractures of the scapula, humerus, elbow, and forearm were associated with inpatient management. During the onset of the COVID-19 pandemic, there was a decrease in outpatient procedures. CONCLUSION: There is a shift toward outpatient surgical management of upper extremity fractures from 2008 to 2021. Application of our findings can serve as an institutional guide to allocate patients to appropriate surgical settings. Moreover, physicians and institutions should be aware of the potential socioeconomic disparities and implement plans to allow for equal access to care.

Management and subsequent outcomes of patellar sleeve injuries: A retrospective case series of 90 pediatric and adolescent patients.

Purpose: This study aims to report the epidemiology of patellar sleeve injuries, describe diagnostic findings and treatment, and assess functional outcomes following different treatments. Methods: A medical database was queried from 1990 to 2016 to identify patients ≤18 years presenting to a single pediatric institution with a patellar sleeve injury. Patients with significant comorbidities or previously operatively treated for ipsilateral knee injuries were excluded. Standard demographic data, mechanism of injury, skeletal maturity, injury-related radiographic parameters, along with treatment paradigms, post-treatment clinical and radiographic findings, and patient-reported outcomes were collected. Results: A total of 90 patients, mean age of 10.7 years (range: 7-17) was included, of which 69 (77%) were male. Seventy-three percent of all injuries occurred while playing sports (particularly football/basketball/soccer), with "direct blow" or "landing" being the most prevalent mechanisms of injury. Twenty-six (29%) underwent operative treatment, with transosseous suture fixation being the most popular surgical technique (73%). Of the 64 (71%) non-operatively treated patients, 18 (39%) were placed in a hinged knee brace locked in extension with the remainder split between casting and standard knee immobilizer. Compared to the non-operative cohort, a higher percentage of the operative group had a pre-treatment extensor lag (p < 0.001) and greater fragment displacement (p < 0.001) with patella alta (p < 0.001) on imaging. There was no difference in outcome scores (Pedi-IKDC/Lysholm) or patella alta on radiographs between groups. Post-treatment surveys indicated no difference in residual pain or ability to return to sport. Conclusion: This large case series provides valuable epidemiologic, clinical, and radiographic data describing patellar sleeve fractures, along with outcomes following non-operative and operative treatments. Level of evidence: IV.

Principles and Evaluation of Bony Unions.

Nonunion is a common and costly problem. Unfortunately, there is no widely agreed upon and standardized definition for nonunion. The evaluation of bony union should start with a thorough history and physical examination. The clinician should consider patient-dependent as well as patient-independent characteristics that may influence the rate of healing and evaluate the patient for physical examination findings suggestive of bony union and infection. Radiographs and clinical examination can help confirm a diagnosis of union. When the diagnosis is in doubt, however, advanced imaging modalities as well as laboratory studies can help a surgeon determine when further intervention is necessary.

Posterior Tibiotalar Impingement After Pediatric Ankle Fracture Surgical Fixation: A Case Report.

CASE: A 13-year-old healthy, nearly skeletally mature, female patient presented to an outpatient clinic after sustaining a bimalleolar ankle fracture-dislocation, which was subsequently treated with open reduction and internal fixation and casting. Postoperatively, the patient had significant limitations to ankle range of motion. Imaging revealed posterior tibiotalar impingement. The patient underwent arthroscopic debridement and osteoplasty, and she was able to return to previous levels of activity. CONCLUSIONS: Complications from pediatric ankle fractures are rare, so further diagnostic workup is warranted for patients with persistent pain and limitations.

Interfacility Transfer Patients With Pelvic, Acetabular, and Lower Extremity Fractures Are at Higher Risk for Major Complications and Readmissions.

OBJECTIVE: To compare the adverse event profile and patient comorbidity profile of lower extremity orthopaedic trauma patients admitted via interfacility transfer (IT) to direct admission (DA) patients from home. METHODS: A total of 39,497 patients from 2012 to 2019 were identified in the American College of Surgeon National Surgical Quality Improvement Program database. DA patients were compared with IT patients for differences in preoperative comorbidities, adverse events, length of stay, and readmissions in the 30-day postoperative period. Student t tests were used to assess continuous variables. Pearson χ 2 test and odds ratios (ORs) were used for categorical variables. RESULTS: The IT group comprised 7167 patients, and the DA group comprised 32,330 patients. IT patients were on average older (65.5 vs. 58.8 years, P < 0.01), more likely to be American Society of Anesthesiologists Status >2 ( P < 0.01), and had a worse comorbidity profile for numerous preoperative risk factors. IT patients had significantly higher rates of mortality [3.3% vs. 1.4%; odds ratio (OR) 2.29; 95% confidence interval (CI), 1.96-2.77], major complications (10.2% vs. 6.1%; OR 1.74; 95% CI, 1.60-1.91), significantly higher readmission rates (5.8% vs. 4.8%, P < 0.01, OR 1.22 95% CI, 1.09-1.36), and more infectious complications (7% vs. 4.7%; OR 1.54; 95% CI, 1.38-1.71) than DA patients. Transfer remained a significant factor predicting major adverse events in regression analysis controlling for patient characteristics and fracture type ( P < 0.01; B 1.197; 95% CI, 1.09-1.32). CONCLUSIONS: This study revealed that IT patients undergoing operative management of pelvic, acetabular, and lower extremity fractures are at a significantly increased risk of major complications, readmission, and have a higher morbidity burden than DA patients. As healthcare transitions to value-based care and bundled payments, hospitals that accept a high volume of ITs will face exposure to added risk and financial penalties without adequate policy protections. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Implant Removal Matrix for the upper Extremity Orthopedic Surgeon.

Orthopedic implant removal is a commonly performed procedure. While implant removal can be associated with improved symptoms, risks of the surgery are notable. Stripped screws, broken and retained hardware, and morbidity associated with soft tissue compromise during difficult removal are all common. Familiarity with the instruments is critical to procedure success. The purpose of this study is to assist removal of unfamiliar screws in upper extremity surgery by offering a reference for screw and driver compatibility across manufacturers. Inclusion of device manufacturers was determined by market share. Screw size, drive configuration, and screw removal system compatibility data was collected and recorded. Screw, guide-wire, and screwdriver compatibility was assessed and compared to two commonly utilized universal implant-removal sets. Eight upper extremity implant vendors were included. The data was compiled in table format according to manufacturer and sub-categorized to facilitate screw identification according to radiographically identifiable characteristics. The diversity of orthopaedic implants in upper extremity surgery requires careful preoperative planning to identify the appropriate equipment for implant removal. The goal of this work is to provide a centralized reference of commonly implanted screws, guide-wires, and drivers for the upper extremity to facilitate removal.

Consideration of medial anatomical structures at risk when placing quadricortical syndesmotic fixation: A cadaveric study.

BACKGROUND: Surgical fixation of syndesmotic instability using quadricortical fixation, whether screws or suture-button devices, places structures on the medial side of the tibia at iatrogenic risk. This study aims to radiographically map the anatomic course of structures on the medial aspect of the distal tibia to be able to at-risk zones (ARZs) for syndesmotic fixation. METHODS: Eighteen fresh-frozen cadaveric ankle specimens were dissected. The saphenous neurovascular bundle (SNVB) and the posterior tibial tendon (PTT) were identified and marked with copper wiring. Standardized and calibrated lateral radiographs of the distal tibia and fibula were analyzed using a grid system consisting of 3 columnar zones from anterior to posterior and five 1-cm rows to chart the anatomic course of the SNVB and the PTT. RESULTS: The SNVB was located in the more anterior zones (1, 2, or anterior to Zone 1) in 97.3% of specimens. The SNVB traversed from posterior to anterior as it descended proximal to distal. The PTT was found in Zone 3 (most posterior zone) for all specimens. The PTT was noted to pass behind (radiographically overlap) the tibia in 83.3% (15 of 18) of specimens between 1 and 3 cm above the tibiotalar joint. CONCLUSIONS: Placement of quadricortical syndesmotic fixation places structures on the medial ankle at risk. The SNVB is at considerable risk along the anterior course of the distal tibial while the PTT is only at risk in zone 3 at the distal extent of the tibia.

Implant Removal Matrix for the Foot and Ankle Orthopaedic Surgeon.

BACKGROUND: Orthopaedic surgery frequently requires the use of metal plate and screw constructs for osteosynthesis. These constructs may be subsequently removed for a variety of indications. In the lower extremity in particular, implants (ie, hardware) can lead to prominence and pain secondary to a thin soft-tissue envelope with little subcutaneous tissue. Often, removal is performed without knowledge of the exact type of screw head configuration and/or size, which can make removal technically challenging. The purpose of this study is to consolidate screw head sizes and configurations from commonly utilized orthopaedic foot and ankle implant manufacturers matched against 2 commonly used universal implant removal sets to aid in the expeditious removal of hardware. METHODS: Orthopaedic manufacturers of foot and ankle-specific implants were included based on market share. Publicly available information on screw size, head configuration, and driver size was collected and recorded. This information was cross-referenced against the drivers available in 2 commonly utilized universal implant removal sets. RESULTS: Seven foot and ankle implant manufacturers were included. The data were compiled in table format according to manufacturer and subcategorized by noncannulated screws, cannulated screws, and locking screws. CONCLUSION: Many factors affect the success of hardware removal, and it is imperative that the surgeon knows which drivers are compatible with the implanted hardware. The expanding magnitude and diversity of orthopaedic implants makes removal of hardware more challenging. A guide of compatible drivers for various screw types helps expedite this procedure. LEVELS OF EVIDENCE: Level V.

Does radial head implant fixation affect functional outcomes? A systematic review and meta-analysis.

BACKGROUND: Radial head arthroplasty is used in the treatment of nonreconstructible radial head fractures. Although traditional implants have been loosely fixed, smooth stemmed implants functioning more as spacers, modern designs have introduced press-fit, tapered implants that articulate at the capitellum with more rigidly maintained congruity. Cemented implants also use rigid initial fixation. This study was conducted to help determine which fixation method results in better functional outcomes: "fixed" or "unfixed." METHODS: A systematic review and meta-analysis was used. We identified 63 articles via 3 databases. Ten non-English or articles with insufficient text were excluded, and 17 others did not contain sufficient data or follow-up. The remaining 36 articles were qualitatively and quantitatively reviewed. RESULTS: We identified 36 populations, with 878 unduplicated patients: 522 fixed and 356 unfixed. Respectively, mean follow-up in months was 46.2 and 37.4. Average Mayo Elbow Performance Scores were 85.9 and 88.2 (P = .08). Average Disabilities of the Arm, Shoulder and Hand scores were 17.1 and 18.7 (P = .47). Average final flexion/extension arcs were 119.1° and 115.8° (P = .08). Revision rates were 7.9% and 3.1%, and complication rates were 25.5% and 13.2%. Relative risks of revision and complications for the fixed cohort were 2.48 (P = .006) and 1.88 (P < 0.0001), respectively. CONCLUSIONS: Implant fixation type does not appear to affect functional outcomes of radial head arthroplasty. However, rigidly fixing the implant may increase the risks of revision and complications.

Nef Is Dispensable for Resistance of Simian Immunodeficiency Virus-Infected Macrophages to CD8+ T Cell Killing.

UNLABELLED: Simian immunodeficiency virus (SIV)-specific CD8(+) T cells kill SIV-infected CD4(+) T cells in an major histocompatibility complex class I (MHC-I)-dependent manner. However, they are reportedly less efficient at killing SIV-infected macrophages. Since the viral accessory protein Nef has been shown to downregulate MHC-I molecules and enhance cytotoxic T lymphocyte (CTL) evasion in human immunodeficiency virus type 1 (HIV-1)-infected CD4(+) T cells, we examined whether Nef played a role in protecting SIV-infected macrophages from killing by SIV-specific CD8(+) T cells. To explore the role of Nef in CD8(+) T cell evasion, we compared the ability of freshly sorted SIV-specific CD8(+) T cells to readily suppress viral replication or eliminate CD4(+) T cells or monocyte-derived macrophages infected with SIV variants containing wild-type (WT) or mutated nef genes. As expected, SIV-specific CD8(+) T cells suppressed viral replication and eliminated the majority of SIV-infected CD4(+) T cells, and this killing was enhanced in CD4(+) T cells infected with the nef variants. However, macrophages infected with nef variants that disrupt MHC-I downregulation did not promote rapid killing by freshly isolated CD8(+) T cells. These results suggest that mechanisms other than Nef-mediated MHC-I downregulation govern the resistance of SIV-infected macrophages to CD8(+) T cell-mediated killing. This study has implications for viral persistence and suggests that macrophages may afford primate lentiviruses some degree of protection from immune surveillance. IMPORTANCE: Myeloid cells are permissive for HIV/SIV replication in vitro and may contribute to viral persistence in vivo. While many studies have been geared to understanding how CD8(+) T cells control viral replication in CD4(+) T cells, the role of these cells in controlling viral replication in macrophages is less clear. Primary, unstimulated CD8(+) T cells insignificantly suppress viral replication or eliminate SIV-infected macrophages. Since the viral Nef protein downregulates MHC-I and provides infected cells some degree of protection from CD8(+) T cell-mediated effector functions, we evaluated whether Nef may be contributing to the resistance of macrophages to CD8(+) T cell suppression. Our results suggest that Nef is not involved in protecting infected macrophages from CD8(+) T cell killing and suggest that other mechanisms are involved in macrophage evasion from CD8 surveillance.

Perception problems of the verbal scale: A reanalysis and application of a membership function approach.

Verbal conclusion scales provide a standardized vocabulary that forensic scientists can adopt to describe the amount of support offered by a set of observations with regard to two competing hypotheses. The extent to which these verbal scales can efficiently and accurately communicate strength of support to lay evaluators is, however, an empirical matter of considerable importance. The aim of this paper was to reexamine the results of a recent study measuring lay interpretations of expert verbal phrases (Mullen et al., 2014) and to further improve upon those estimates through the utilization of a membership function approach. Across both the reexamination (n=400) and the new experiment (n=134) 534 participants provided translations of expert verbal conclusion scales used by forensic scientists. Overall, there is compelling evidence that the correspondence between expert intentions and lay interpretations is low, while the potential for miscommunication is high. Consequently, further attention is required to facilitate the development of valid and reliable verbal conclusion scales which clearly communicate expert evaluative opinions.

The expression and interpretation of uncertain forensic science evidence: verbal equivalence, evidence strength, and the weak evidence effect.

Standards published by the Association of Forensic Science Providers (2009, Standards for the formulation of evaluative forensic science expert opinion, Science & Justice, Vol. 49, pp. 161-164) encourage forensic scientists to express their conclusions in the form of a likelihood ratio (LR), in which the value of the evidence is conveyed verbally or numerically. In this article, we report two experiments (using undergraduates and Mechanical Turk recruits) designed to investigate how much decision makers change their beliefs when presented with evidence in the form of verbal or numeric LRs. In Experiment 1 (N = 494), participants read a summary of a larceny trial containing inculpatory expert testimony in which evidence strength (low, moderate, high) and presentation method (verbal, numerical) varied. In Experiment 2 (N = 411), participants read the same larceny trial, this time including either exculpatory or inculpatory expert evidence that varied in strength (low, high) and presentation method (verbal, numerical). Both studies found a reasonable degree of correspondence in observed belief change resulting from verbal and numeric formats. However, belief change was considerably smaller than Bayesian calculations would predict. In addition, participants presented with evidence weakly supporting guilt tended to "invert" the evidence, thereby counterintuitively reducing their belief in the guilt of the accused. This "weak evidence effect" was most apparent in the verbal presentation conditions of both experiments, but only when the evidence was inculpatory. These findings raise questions about the interpretability of LRs by jurors and appear to support an expectancy-based account of the weak evidence effect.

Low tyrosine content of growth media yields aflagellate Salmonella enterica serovar Typhimurium.

Identification of Salmonella serotypes is based on flagellar and somatic antigens. The absence of flagella may consequently affect complete identification of the serotype; here it is shown that Salmonella enterica serovar Typhimurium exhibits morphological differences dependent on the peptone constituents of the culture medium. Aflagellate salmonella were produced in certain media where the nutritional ingredient was casein-based peptone or gelatin-based peptone; in gelatin-based peptone, aggregates of salmonella were observed. However, in media containing soy-based peptone as the primary nutrient, salmonella displayed a normal flagellated morphology. Transfer of aflagellate salmonella from nutritionally poor media, with casein- or gelatin-based peptone, into rich nutrient broth allowed flagella synthesis, indicating that the aflagellate form is still able to produce flagella. Amino acid sequencing of the peptones producing aflagellate organisms showed a relatively low tyrosine concentration: only 0.03+/-0.01 g l(-1) for gelatin-based buffered peptone water, compared to 0.21+/-0.01 for soy-based buffered peptone water. Tyrosine is essential for flagellin, which is the subunit of the salmonella flagellar filament. The addition of 200 muM tyrosine to casein-based peptone media produced flagellate salmonella; 2 mM glucose was needed in addition to tyrosine to achieve a similar morphology in gelatin-based media. Therefore, culture media containing less than 1.20 g tyrosine l(-1), and of limited carbohydrate source, when used for serological testing of clinical isolates, may result in an incomplete serological identification.