Building Blocks of Wellness: Where Do We Start When Our Tasks Have No End?

Surgeon wellness, and the means by which it may be realized, has recently come to the forefront as awareness of burnout among orthopaedic surgeons has increased. Individual surgeons face unique challenges toward finding their own path to thrive. It is important to incorporate varying perspectives regarding potential solutions to surgeons' stresses in both work and extracurricular life. Specifically, the goal is to initiate a discussion regarding wellness by providing insight into the challenges facing surgical residents, supplemented with the perspectives of women and minorities within the field. Peer coaching plays an essential role in optimizing mental health.

Sex steroid-induced DNA methylation changes and inflammation response in prostate cancer.

BACKGROUND: Sex steroid hormones have been reported to induce inflammation causing dysregulation of cytokines in prostate cancer cells. However, the underlying epigenetic mechanism has not well been studied. The objective of this study was to evaluate the effect of sex steroid hormones on epigenetic DNA methylation changes in prostate cancer cells using a signature PCR methylation array panel that correspond to 96 genes with biological function in the human inflammatory and autoimmune signals in prostate cancer. Of the 96-gene panel, 32 genes showed at least 10% differentially methylation level in response to hormonal treatment when compared to untreated cells. Genes that were hypomethylated included CXCL12, CXCL5, CCL25, IL1F8, IL13RAI, STAT5A, CXCR4 and TLR5; and genes that were hypermethylated included ELA2, TOLLIP, LAG3, CD276 and MALT1. Quantitative RT-PCR analysis of select genes represented in a cytokine expression array panel showed inverse association between DNA methylation and gene expression for TOLLIP, CXCL5, CCL18 and IL5 genes and treatment of prostate cancer cells with 5'-aza-2'-deoxycytidine with or without trichostatin A induced up-regulation of TOLLIP expression. Further analysis of relative gene expression of matched prostate cancer tissues when compared to benign tissues from individual patients with prostate cancer showed increased and significant expression for CCL18 (2.6-fold; p<0.001), a modest yet significant increase in IL5 expression (1.17-fold; p=0.015), and a modest increase in CXCL5 expression (1.4-fold; p=0.25). In conclusion, our studies demonstrate that sex steroid hormones can induce aberrant gene expression via differential methylation changes in prostate carcinogenesis.

Acute Compartment Syndrome in the Athlete.

In sports, acute compartment syndrome (ACS) develops following lower limb fracture, with subsequent high intracompartmental pressures and pain out of proportion to the physical examination. A prompt diagnosis is the key to a successful outcome in patients with ACS. The goal of treatment of ACS, namely decompressive fasciotomy, is to reduce intracompartmental pressure and facilitate reperfusion of ischemic tissue before onset of necrosis. A delay in diagnosis and treatment may result in devastating complications, including permanent sensory and motor deficits, contractures, infection, systemic organ failure, limb amputation, and death.

Social Media Use Continues to Increase Among Orthopaedic Residency Programs in the United States.

PURPOSE: To evaluate the social media usage of orthopaedic residency programs, program directors (PDs), and department chairs across Instagram, Facebook, and Twitter and to determine which types of social media posts are indicative of increased user following. METHODS: A systematic online search strategy was performed in October 2020 to identify all allopathic orthopaedic surgery residency program accounts on Instagram, Facebook, and Twitter. Instagram posts were further analyzed to evaluate the type of post that significantly correlated with increased follower counts. RESULTS: Of 158 orthopaedic surgery programs, 69 (43.7%) had Instagram accounts, 52 (32.9%) had Facebook accounts, and 54 (34.2%) had Twitter accounts. Program presence on Instagram and Twitter continued to grow exponentially (R 2 = 0.99 and R 2 = 0.95, respectively). Regarding program leadership, a total of 151 PDs and 156 chairs were identified. Of these, 21 PDs (14%) and 8 chairs (5.1%) had Instagram accounts. The number of posts and the numbers of educational, social, program information, and operative posts (P < .01) significantly correlated with increased followers on Instagram. CONCLUSIONS: Fewer than one-half of orthopaedic surgery residency programs and fewer than one-quarter of PDs and department chairs have a social media presence. However, the number of residency programs on social media continues to rise year-over-year. The total number of posts; the amount of educational, social, and program information; and the number of operative posts significantly correlated with increased followers on Instagram. CLINICAL RELEVANCE: With the growing prevalence of social media, orthopaedic surgery residency programs have the opportunity to connect with future applicants and disseminate informational content regarding their programs.

Older, Heavier, Arthritic, Psychiatrically Disordered, and Opioid-Familiar Patients Are at Risk for Opioid Use After Medial Patellofemoral Ligament Reconstruction.

PURPOSE: To investigate which factors predispose patients for prolonged opioid use after medial patellofemoral ligament (MPFL) reconstruction. METHODS: A retrospective review of all patients who underwent MPFL reconstruction at a single institution between January 2013 and June 2020 was conducted. Opioid consumption before and after surgery was recorded and confirmed using Michigan Automated Prescriptions System monitoring program. Patients were classified into preoperative opioid users and nonusers. Risk factors for continued opioid use were assessed by collecting patient demographic variables, psychiatric history, number of previous patellar dislocations, and operative factors. RESULTS: A total of 102 patients were included during the time frame of interest. Patients were on average 21.6 ± 8.5 years old with a mean body mass index of 28.2 ± 7.9. Thirty patients (29.0%) sustained >10 dislocations preoperatively. Preoperative opioid use was present in 13 (12.7%) patients. Greater than 10 dislocations (odds ratio [OR] 5.00, 95% confidence interval [CI] 1.12-20.92) and psychiatric history (OR 3.33, 95% CI, 1.2-9.1; P = .016) significantly predicted opioid refills the first month after surgery. Risk factors for opioid refills at 2 to 12 months postoperatively included smoking (OR 4.50, 95% CI 1.13-17.96), preoperative opioid use (OR 7.32, 95% CI 1.88-28.47), psychiatric disorder (OR 3.77, 95% CI 2.3-6.2; P < .001), age >30 years (OR 7.03, 95% CI 3.63-13.61; P < .001), and obesity (OR 2.68, 95% CI 1.40-5.14; P = .002). Compared with Outerbridge 0, a greater percentage of patients with Outerbridge 1 or 2 and 3 or 4 continued using opioids 2 to 12 months after surgery (OR 3.06, 95% CI 1.33-7.02; P = .006 and OR 2.86, 95% CI 1.24-6.59; P = .010, respectively). CONCLUSIONS: For patients undergoing MPFL reconstruction, preoperative opioid use, cartilage damage, age >30 years, smoking history, body mass index >30, and history of psychiatric disorder were found to be significantly associated with prolonged opioid use after surgery. Postoperative opioid refills in this cohort declined after 1 month. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

The immunophenotype of decidual macrophages in acute atherosis.

PROBLEM: Acute atherosis is a uteroplacental arterial lesion that is associated with pregnancy complications such as preeclampsia and preterm birth, the latter being the leading cause of perinatal morbidity and mortality worldwide. However, the immunobiology of acute atherosis is poorly understood. METHOD OF STUDY: Placental basal plate samples were collected from women who delivered with (n = 11) and without (n = 31) decidua basalis lesions of acute atherosis. Multicolor flow cytometry was used to quantify M1- and M2-like macrophage subsets and the expression of iNOS and IL-12 by decidual macrophages. Multiplex fluorescence staining and phenoptics were performed to localize M1-, MOX-, and Mhem-like macrophages in the decidual basalis. RESULTS: Macrophages displayed diverse phenotypes in the decidua basalis with acute atherosis. M2-like macrophages were the most abundant subset in the decidua; yet, this macrophage subset did not change with the presence of acute atherosis. Decidual M1-like macrophages were increased in acute atherosis, and such macrophages displayed a pro-inflammatory phenotype, as indicated by the expression of iNOS and IL-12. Decidual M1-like pro-inflammatory macrophages were localized near both transformed and non-transformed vessels in the decidua basalis with acute atherosis. MOX and Mhem macrophages were also identified near transformed vessels in the decidua basalis with acute atherosis. Finally, monocyte-like cells were present on the vessel wall of non-transformed decidual vessels, indicating a possible intravascular source for macrophages in acute atherosis. CONCLUSION: Decidual macrophages display different phenotypes, namely M1-like, M2-like, MOX, and Mhem subsets. Yet, pro-inflammatory macrophages are enriched in the decidua basalis with acute atherosis. These findings provide a molecular foundation for future mechanistic inquiries about the role of pro-inflammatory macrophages in the pathogenesis of acute atherosis.