A cadaveric study of radial and ulnar bowing in the sagittal and coronal planes.

BACKGROUND: This study provides a comprehensive, full-length assessment of radial and ulnar bowing in anteroposterior (AP) and sagittal planes. METHODS: Radial and ulnar AP and lateral bowing were assessed using orthogonal digital photographs of 211 randomly selected cadaveric bilateral forearms (422 radius, 422 ulna bones) from a well-preserved osteologic collection. RESULTS: In the radial AP plane, an apex-radial bow was present at a mean of 58% of bone length (slightly distal to midpoint), with a mean depth of 1.3 cm. In the radial lateral plane, an apex-dorsal bow occurred at a mean of 45% of bone length, with a mean depth of 0.8 cm. In the ulnar AP plane, apex-radial bow occurred at a mean of 32% of bone length with a mean depth of 1.0 cm. In the ulnar lateral plane, the majority of specimens (81%) had an apex-dorsal bow, whereas 19% had a reverse (apex-volar) bow. Lateral ulnar bow was located at a mean of 33% of bone length with a mean depth of 2.0 cm, with 36% of specimens possessing a lateral bow located at 35% or more distal along the ulna. Side-to-side differences for bow location and depth were less than 2% of bone length. CONCLUSIONS: Ulnar lateral bow was found to be more distal than in previously published works, which analyzed only the proximal ulna, and this study describes a reverse ulnar bow in 19% of specimens. This demonstrates lateral ulnar morphology to be more variable than previously defined with minimal side-to-side variability, which are important considerations for fracture fixation and elbow arthroplasty.

Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center.

BACKGROUND: Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality. RESULTS: Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84-0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72-0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race. CONCLUSIONS: Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.

Complications and Functional Outcomes After Pantalar Dislocation.

BACKGROUND: Pantalar dislocations without associated talar fracture are rare and have high risks of complications, including infection, osteonecrosis, and posttraumatic osteoarthrosis. Limited information on later function exists. This study evaluated complications and outcomes following pantalar dislocation without talar fracture. METHODS: Nineteen patients were identified with open (n = 14) or closed (n = 5) pantalar dislocations without talar fracture. Ten male and 9 female patients with a mean age of 39.6 years (range, 19 to 68 years) were included. Open injuries underwent surgical debridement. Sixteen patients had open reduction, and 2 had closed reduction. Fixation was achieved with Kirschner wires (n = 4), external fixation (n = 9), or both (n = 3). Two patients did not have fixation. Another patient had primary transtibial amputation due to nonreconstructible foot trauma. Charts and radiographs were reviewed to identify infection, osteonecrosis, and posttraumatic arthrosis. Data on pain, medications, range of motion, and secondary procedures were collected. After a minimum of 1 year, Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) surveys were administered. RESULTS: The mean clinical follow-up was 45.1 months. Two patients had superficial wound-healing problems with prolonged drainage, which healed with dressing changes and oral antibiotics, and 1 patient developed cellulitis 4 months after injury, which resolved with intravenous antibiotics. No deep wound infections occurred. Fourteen (88%) of the 16 patients with a minimum of 11 months of radiographic follow-up developed osteonecrosis, 2 with collapse of the talar dome, and 7 (44%) developed arthrosis of ≥1 peritalar articulation. Outcome surveys were obtained for 11 (58%) of the 19 patients, at a mean of 5.2 years after injury. The mean MFA score was 30.3, and the mean FFI score was 25.3. Six of 10 survey respondents had returned to employment, but 88% (14 of 16) of the patients with radiographic and clinical follow-up reported at least mild pain and 75% (12 of 16) were taking analgesics. CONCLUSIONS: Urgent surgical debridement of open injuries and reimplantation of the talus after pantalar dislocation was not associated with deep infection. Osteonecrosis occurred in the majority of patients, but collapse was uncommon. Persistent pain and functional limitations are frequent after pantalar dislocation, as reflected in extremity-specific and generalized functional outcome scores. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Psychiatric Illness Is Common Among Patients with Orthopaedic Polytrauma and Is Linked with Poor Outcomes.

BACKGROUND: Psychiatric disorders are common, and their functional consequences may be underappreciated by non-mental health-care providers. There exist limited data regarding the frequency of psychiatric illness in patients who sustain orthopaedic polytrauma. The purpose of this study was to describe the prevalence of psychiatric illness in patients with orthopaedic polytrauma, to determine whether psychiatric illnesses were identified and were accommodated by trauma providers, and, finally, to investigate any associations between postoperative complications and psychiatric illness. METHODS: Three hundred and thirty-two skeletally mature patients with surgically treated axial and/or femoral fractures and injuries to other body systems (Injury Severity Score of ≥ 16 points) were identified from a database at a Level-I trauma center. These included 238 men and ninety-four women with a mean value (and standard deviation) of 39 ± 16 years for age and 27 ± 12 points for the Injury Severity Score. Records were reviewed for preexisting diagnoses of psychiatric disorders. The inpatient courses and discharge recommendations regarding treatment of psychiatric illness were analyzed. Complications in the six-month postoperative period were determined by an independent committee. RESULTS: Preexisting psychiatric disorders were identified in 130 patients (39.2%), including depression in seventy-four patients (22.3%) and substance abuse in fifty-six patients (16.9%). Patients managed by an orthopaedic surgery service were less likely to receive their home psychiatric medications while hospitalized (p = 0.001) and were less likely to receive instructions for psychiatric follow-up at discharge (p = 0.087). Postoperative complications occurred in sixty-six patients (19.9%) overall; depression was an independent predictor of increased complications, with an odds ratio of 2.956 (95% confidence interval, 1.502 to 5.816). CONCLUSIONS: Psychiatric illness was common among individuals who sustained orthopaedic polytrauma, and patients with depression had more complications. This study highlights the need for greater attention to mental health disorders in this population.

Anatomic Investigation of Commonly Used Landmarks for Evaluating Rotation During Forearm Fracture Reduction.

BACKGROUND: Evaluating rotation during open reduction and internal fixation of a forearm fracture is of paramount importance. In challenging cases, surgeons may utilize radiographic relationships between proximal and distal radial and ulnar landmarks to assess rotational position. However, to our knowledge, limited anatomic data are available to confirm these relationships. METHODS: Six hundred cadaveric radii and ulnae were obtained. Digital representations of the bicipital tuberosity, the radial styloid, the coronoid process, and the ulnar styloid were acquired, and the rotational profiles between respective landmarks were calculated. In order to validate the results and investigate the ability to differentiate rotated osseous positions, each bone was imaged in increments of 10° of rotation and the profile of each landmark was measured. RESULTS: The radial styloid was at a mean of 158° ± 14° of supination relative to the bicipital tuberosity. The ulnar styloid was at a mean of 185° ± 14° of supination relative to the coronoid process. Imaging of the bones in increments of 10° of rotation supported the relationships above. It was also found that a 1-mm difference in profile size corresponded to up to 60° of rotation for the average ulna, compared with 10° for the average radius. CONCLUSIONS: Our findings suggest that using the bicipital tuberosity and the radial styloid to assess intraoperative rotation of the radius on anteroposterior radiographs may be of limited value; the landmarks were not generally 180° apart. Although the rotational positions of the coronoid process and the ulnar styloid were, on average, closer to 180°, surgeons should be aware of the wide range of normal anatomy as well as the inability to judge rotation by as much as 60°, even for an "ideal" ulna. CLINICAL RELEVANCE: This study, to our knowledge, represents the first anatomic investigation of the rotational profiles between the osseous landmarks used to assess forearm rotation after fracture. We recommend that surgeons first image the bicipital tuberosity at its largest profile, supinate the arm 20°, and confirm that the radial styloid is at its largest profile. The ulna can then be assessed to support the lack of rotational deformity in the forearm.

Relation of Echocardiographic Characteristics of the Right-Sided Heart With Incident Heart Failure and Mortality in Patients With Sleep-Disordered Breathing and Preserved Left Ventricular Ejection Fraction.

Sleep-disordered breathing (SDB) has been associated with right-sided heart dysfunction and adverse cardiovascular outcomes. Longitudinal data are sparse in terms of understanding the prognostic implications of right ventricular remodeling in SDB on cardiovascular risk. We therefore investigated the predictive value of right-sided cardiac functional alterations on incident heart failure (HF) or death in SDB. Patients with SDB who underwent echocardiography within 1 month of index polysomnogram from January 2002 to July 2011 with normal left ventricular ejection fraction were included. Cox proportional prognostic hazard models predicting HF or death were used. Of a potential 375 subjects, 202 fulfilled the inclusion criteria (58 ± 14 years; 50% men). Subjects were followed for 3.1 ± 2.4 years with a total of 34 (16.8%) developing HF or death. Right ventricular end-systolic area (hazard ratio [HR] 1.3, 95% CI 1.01 to 1.6, p = 0.038), pulmonary vascular resistance (PVR; HR 1.4, 95% CI 1.1 to 1.7, p = 0.005) and also left atrial volume index (HR 1.7, 95%, CI 1.3 to 2.3, p <0.001) and E/A ratio (HR 1.4, 95% CI 1.1 to 1.7, p <0.001), were predictive of HF or death. Patients with increased PVR had significantly shorter event-free survival than without increased PVR (p = 0.04). In sequential Cox models, a model based on clinical data and left ventricular ejection fraction (χ2, 5.4) was improved by left atrial volume index (χ2, 12.7; p = 0.011) and further increased by PVR (χ2, 19.7; p = 0.015). In conclusion, right-sided heart dysfunction provides important prognostic information in SDB and may aid in identifying those at highest risk to target for closer follow-up.

Cystic Fibrosis Patents: A Case Study of Successful Licensing.

From 2006-2010, Duke University's Center for Public Genomics prepared eight case studies examining the effects of gene patent licensing practices on clinical access to genetic testing for ten clinical conditions. One of these case studies focused on the successful licensing practices employed by the University of Michigan and the Hospital for Sick Children in Toronto for patents covering the CFTR gene and its ΔF508 mutation that causes a majority of cystic fibrosis cases. Since the licensing of these patents has not impeded clinical access to genetic testing, we sought to understand how this successful licensing model was developed and whether it might be applicable to other gene patents. We interviewed four key players who either were involved in the initial discussions regarding the structure of licensing or who have recently managed the licenses and collected related documents. Important features of the licensing planning process included thoughtful consideration of potential uses of the patent; anticipation of future scientific discoveries and technological advances; engagement of relevant stakeholders, including the Cystic Fibrosis Foundation; and using separate licenses for in-house diagnostics versus kit manufacture. These features led to the development of a licensing model that has not only allowed the patent holders to avoid the controversy that has plagued other gene patents, but has also allowed research, development of new therapeutics, and wide-spread dissemination of genetic testing for cystic fibrosis. Although this licensing model may not be applicable to all gene patents, it serves as a model in which gene patent licensing can successfully enable innovation, investment in therapeutics research, and protect intellectual property while respecting the needs of patients, scientists, and public health.