Greater Socioeconomic Deprivation is Associated with Increased Complication Rates and Lower Patient-Reported Outcomes Following Open Reduction and Internal Fixation of Humeral Shaft Fractures.

OBJECTIVES: This study explored the hypothesis that social determinants of health (SDOH), including racial and economic differences, may impact orthopaedic trauma outcomes in patients undergoing open reduction and internal fixation (ORIF) of humeral shaft fractures. METHODS: Design: Retrospective. SETTING: Single, academic, tertiary Level-I trauma center. PATIENT SELECTION CRITERIA: Adults with midshaft humerus fractures (AO/OTA 12) treated operatively with plate fixation from 05/2011 to 05/2021 with a minimum follow-up of nine months. OUTCOME MEASURES AND COMPARISONS: Radiographic fracture healing, complication rates, and patient-reported outcomes were investigated. SDOH were assessed using the Area Deprivation Index (ADI). Demographics, complications rates, and patient-reported clinical outcomes were compared between the first and fourth ADI quartiles. RESULTS: 196 patients fit the study criteria. The average age of the cohort was 47 years with 50 women (51%). Comparisons of the least deprived quartile (n=49) to the most deprived quartile (n=49) yielded similar sex distribution (59% vs 43% female, p=0.15), fewer non-white patients (8% vs 51%, p<0.01), older average age (51 years vs 43 years, p=0.05), similar BMI (30.5 vs. 31.8, p=0.45), and higher Charlson Comorbidity Index (CCI) (2.2 vs.1.1, p=0.03). While nonunion rates were similar (p=0.20) between groups, the most deprived quartile had 2.3 times greater odds of post-operative complications (p=0.04). Patients in the most deprived group exhibited higher PROMIS Pain Interference (PI) scores (p<0.01) and PROMIS Depression (D) scores (p=0.01), with lower PROMIS Physical Function (PF) scores (p<0.01) at 6-month follow-up than the least depriver cohort. The most deprived cohort had three times higher odds of missing scheduled appointments within the first post-operative year (p<0.01), resulting in a significantly higher no-show rate (p<0.01) than the least deprived cohort. Regression analysis including several demographic and injury factors identified that ADI was significantly associated with the occurrence of any missed appointments (p<0.01), no-show rates (p=0.04), and experiencing one of the following post-operative complications during recovery: Nonunion, radial nerve injury, or dysfunction (p=0.03). CONCLUSIONS: Patients experiencing greater resource deprivation faced increased odds of complications, missed appointments, and poorer PROMIS outcomes following humeral shaft fracture fixation, emphasizing that baseline socioeconomic disparities predict unfavorable post-operative outcomes even given favorable baseline health status according to the CCI score. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

No Differences in Clinical, Functional, or Patient-Reported Outcomes Following Trial of Nonoperative Management Before Open Reduction and Internal Fixation of Humeral Shaft Fractures.

OBJECTIVES: To test the hypothesis that primary osteosynthesis of humeral shaft fractures may lead to more favorable clinical, functional, and patient-reported outcomes than fixation following a trial of nonoperative management. DESIGN: Retrospective cohort review. SETTING: Academic level I trauma center. PATIENT SELECTION CRITERIA: Adult patients who presented with humeral shaft fractures and ultimately underwent open reduction and internal fixation (ORIF) from May 2011 to May 2021. Patients who underwent ORIF within 2 weeks of injury were grouped into the primary osteosynthesis cohort, and patients who underwent ORIF >4 weeks from the date of injury were grouped into the trial of nonoperative cohort. OUTCOME MEASURES AND COMPARISONS: Postoperative complications, elbow arc of motion, time to radiographic union, and patient-reported outcomes were investigated and compared between the primary osteosynthesis and trial of nonoperative management cohorts. RESULTS: One hundred twenty-seven patients fit the study criteria, 84 underwent primary osteosynthesis and 43 trialed initial nonoperative treatment. No differences were found in patient demographics between the primary osteosynthesis and trial of nonoperative management cohorts, including age (53 ± 19 vs. 57 ± 18; P = 0.25), sex (39% vs. 44% male, 61% vs. 56% female; P = 0.70), and Body Mass Index (BMI) (30 ± 6 vs. 32 ± 9; P = 0.38). The average time to operative intervention in the primary osteosynthesis group was 4 days (0-14 days) and 105 days (28-332 days) in the trial of nonoperative treatment group ( P < 0.01). No differences were found with regard to intraoperative blood loss, total operative time, time to radiographic union (determined using the Radiographic Union Scores for Humeral scoring system), or overall complication rates, including primary and secondary radial nerve injuries ( P = 0.23 and 0.86, respectively). Patients reported similar patient-reported outcomes measurement information system pain interference ( P = 0.73), depression (D) ( P = 0.99), and physical function ( P = 0.66) scores at their 6-month postsurgical follow-up visits. CONCLUSIONS: Patients who attempted a trial of nonoperative management for humeral shaft fractures before ORIF had similar clinical, functional, and patient-reported outcomes as those who underwent primary osteosynthesis. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparable Injury to the Indirect Head of the Rectus Femoris During Interportal and Periportal Capsulotomy: A Cadaveric Study.

Background: There is concern for maintaining the integrity of the reflected head of the rectus femoris during arthroscopic hip joint access. Because of the proximity to the indirect head of the rectus femoris (IHRF), capsulotomy technique and capsular closure during routine hip arthroscopy may play a role in postoperative tendinitis. Purpose: To quantify the extent of injury sustained to the IHRF during interportal versus periportal capsulotomy for routine arthroscopic hip joint access. Study Design: Controlled laboratory study. Methods: A cadaveric study was conducted using 20 fresh-frozen cadaveric hips, in which hip joint access through a periportal capsulotomy (n = 10) or interportal capsulotomy (n = 10) was performed. Capsular closure followed by a layered dissection to the capsuloligamentous complex of the hip joint was then performed to localize the IHRF. Suture proximity to the tendon, tendon disruption, and the IHRF footprint was documented to the nearest 0.01 mm using digital calipers. Statistical analysis was performed using unpaired Student t tests. Results: The mean capsulotomy length for the interportal specimens was 19.27 ± 3.25 mm, and the mean medial and lateral capsulotomy length for the periportal specimens was 4.47 ± 1.60 and 4.26 ± 0.89 mm, respectively. There was violation of the tendon in 3 of 10 interportal specimens and 4 of 10 periportal specimens. There was no significant difference in the closest suture measured to the IHRF for specimens with versus without tendon violation, for either interportal or periportal capsulotomy. Conclusion: We found comparable outcomes with regard to violation of the IHRF between interportal and periportal capsulotomy, with no significant difference in suture proximity to the IHRF in specimens with or without tendon violation. There remains no consensus on the ideal method by which to avoid iatrogenic damage to the IHRF. Clinical Relevance: Our findings provide insight that may lead to future advances in surgical care, such that protection of the tendon during routine hip arthroscopy may allow for improved postoperative rehabilitation and strength.

Increased Neighborhood Deprivation Is Associated with Prolonged Hospital Stays After Surgical Fixation of Traumatic Pelvic Ring Injuries.

BACKGROUND: The purpose of this study was to understand the role of social determinants of health assessed by the Area Deprivation Index (ADI) on hospital length of stay and discharge destination following surgical fixation of pelvic ring fractures. METHODS: A retrospective chart analysis was performed for all patients who presented to our level-I trauma center with pelvic ring injuries that were treated with surgical fixation. Social determinants of health were determined via use of the ADI, a comprehensive metric of socioeconomic status, education, income, employment, and housing quality. ADI values range from 0 to 100 and are normalized to a U.S. mean of 50, with higher scores representing greater social deprivation. We stratified our cohort into 4 ADI quartiles. Statistical analysis was performed on the bottom (25th percentile and below, least deprived) and top (75th percentile and above, most deprived) ADI quartiles. Significance was set at p < 0.05. RESULTS: There were 134 patients who met the inclusion criteria. Patients in the most deprived group were significantly more likely to have a history of smoking, to self-identify as Black, and to have a lower mean household income (p = 0.001). The most deprived ADI quartile had a significantly longer mean length of stay (and standard deviation) (19.2 ± 19 days) compared with the least deprived ADI quartile (14.7 ± 11 days) (p = 0.04). The least deprived quartile had a significantly higher percentage of patients who were discharged to a resource-intensive skilled nursing facility or inpatient rehabilitation facility compared with those in the most deprived quartile (p = 0.04). Race, insurance, and income were not significant predictors of discharge destination or hospital length of stay. CONCLUSIONS: Patients facing greater social determinants of health had longer hospital stays and were less likely to be discharged to resource-intensive facilities when compared with patients of lesser social deprivation. This may be due to socioeconomic barriers that limit access to such facilities. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Editorial Commentary: Social Determinants of Health Influence the Success of Shoulder Rotator Cuff Repair Outcomes: When You Do Everything Right, Yet Things Still Go Wrong.

Our ability to perform a technically sound surgery is not sufficient to ensure patients have an excellent clinical outcome. Social determinants of health disparities (SDHDs) profoundly impact health equality. Health disparities that exist in the United States are risk factors for inferior patient-reported outcomes and result in greater complication rates following rotator cuff repair surgery. The presence of SDHDs was associated with an increased risk of revision, stiffness, emergency department visits, medical complications, and costs. Economic and educational SDHDs were associated with the greatest risk of 1-year revision surgery. Improved understanding of these social variables can help with risk identification preoperatively. Surgeons may employ additional, holistic, bio-psycho-social, perioperative resources to provide high-quality, value-based care to at-risk patients who might be marginalized by our health care system.

Segmental and Circumferential Acetabular Labral Reconstruction Have Comparable Outcomes in the Treatment of Irreparable or Unsalvageable Labral Pathology: A Systematic Review.

PURPOSE: To perform a systematic review comparing outcomes of segmental versus circumferential arthroscopic labral reconstruction as a treatment for symptomatic irreparable or unsalvageable acetabular labral pathology. METHODS: A systematic review was conducted according to PRISMA guidelines using defined inclusion and exclusion criteria. The study groups were divided into segmental and circumferential labral reconstructions. Studies with <2 years follow up, overlapping patient populations, or indications for labral reconstruction other than irreparable or unsalvageable pathology were excluded. RESULTS: The literature search resulted in nine included publications. Five studies presented data on segmental labral reconstruction (166 hips in 164 patients), and seven studies presented data on circumferential labral reconstruction (261 hips in 253 patients). All circumferential reconstruction studies used allograft only, while segmental studies used a combination of autograft and allograft. The range of conversion to total hip arthroplasty was 9.1% to 26.8% in the segmental studies and 3.1% to 9.9% in the circumferential studies. The modified Harris Hip Score (mHHS) was the only patient-reported outcome measure reported in three or more studies in both groups. The mean change from preoperative to postoperative mHHS ranged from 17.8 to 29 in the segmental group and from 20.4 to 31.7 in the circumferential group. Weighted estimates were not calculated due to significant heterogeneity for both the segmental and circumferential groups (I2 = 63.9% and 72.9%, respectively). CONCLUSIONS: Segmental and circumferential reconstructions are both reasonable options for arthroscopic treatment of irreparable or unsalvageable labral pathology. Articles in both groups demonstrated improvement in patient-reported outcomes (mHHS). Because of study heterogeneity, low level of evidence, and high risk of bias, the scores were unable to be directly compared. Although there are theoretical biomechanical and technical advantages of one technique over another, this systematic review did not demonstrate clinical superiority of either technique. LEVEL OF EVIDENCE: Level IV, systematic review of level III and IV studies.

Distal Femoral Replacement and Periprosthetic Joint Infection After Non-Oncological Reconstruction: A Retrospective Analysis.

BACKGROUND: Distal femoral replacement (DFR) is commonly used to manage massive bone loss around the knee arising from aseptic loosening, periprosthetic joint infection (PJI), and distal femoral fractures. A number of studies report the outcome of DFR with considerable variation in long-term survivorship. This study investigated the outcome of DFR for patients with aseptic failures, fractures, and PJI. METHODS: A retrospective review of 182 patients who underwent DFR for non-oncological indications between 2002 and 2018 was conducted. Data collected included the following: indication, postoperative complications, reoperation, revision, and follow-up. Implant survivorship with Kaplan-Meier curves along with a log-rank test for different preoperative indications was performed. A Cox regression model was used to evaluate the risk of revision. RESULTS: The overall postoperative complication rate was very high at 36%. The most common complication was PJI (17%). The rate of reoperation for any cause was 29.7%, and the revision rate was 13.7%. The most common cause of re-revision was PJI (7.1%). Revision-free survivorship of the DFR implant was 91.6% at 1 year, 87.9% at 2 years, 82.5% at 5 years, and 73.4% at 10 years. Patients who had a prior-PJI had the lowest survivorship compared to patients undergoing DFR for management of periprosthetic fracture and mechanical loosening. Additionally, the prior-PJI group was at a fourfold increased risk of postoperative PJI compared to the aseptic group. CONCLUSION: DFR is a valuable reconstructive option for patients with massive bone loss around the knee. However, patients undergoing DFR are at high risk of complications, reoperations, and failure.

Surgical Technique: Repair of Patella Tendon Rupture in a Previously Harvested Tendon for an Anterior Cruciate Ligament Reconstruction.

BACKGROUND: A rare cause of patellar tendon (PT) ruptures is complications after bone-PT-bone (BPTB) graft harvest for anterior cruciate ligament (ACL) reconstruction. The atypical tear pattern in these patients can be technically challenging to address. DESCRIPTION OF TECHNIQUE: A Krackow suture fixation of the medial, tibial based PT was fixed with a knotless suture anchor to the patella. A Krackow suture fixation of the lateral, patella based PT was fixed with a knotless suture anchor to the tibia. Fiber Tape was used for an Internal Brace. PATIENT AND METHODS: We retrospectively reviewed a single patient with a proximal-medial and distal-lateral PT rupture following BPTB graft harvest for an ACL reconstruction. The described repair technique was used to repair the PT rupture. Follow-up was 6-months. Range of motion (ROM), functional outcome scores, and patient-reported outcomes were assessed and recorded. RESULTS: Six-months postoperatively, the patient has regained full knee extension and flexion to 130 degrees. The patient has good quadriceps strength, and manual muscle testing shows no deficits in the operative leg. The patient is able to perform all of her activities of daily living and is discharged from physical therapy. CONCLUSION: We describe a novel technique that effectively repairs the atypical PT rupture pattern seen after ACL reconstruction using BPTB autograft. This technique allows for aggressive post-operative rehabilitation in ROM and strengthening. LEVEL OF EVIDENCE: Level V.

Chronic Tophaceous Gout Presenting as Bilateral Knee Masses in an Adult Patient: A Case Report.

INTRODUCTION: Gout is a common disorder of uric acid metabolism that leads to the precipitation of monosodium urate crystals. It most commonly affects the first metatarsophalangeal joint but can also affect other joints such as knees, elbows, wrists, and ankles. Chronic gout can present as recurrent episodes of monoarticular or polyarticular inflammatory arthritis, tophaceous soft tissue deposits of monosodium urate crystals, uric acid renal calculi, and/or chronic nephropathy. CASE REPORT: We report the case of a 67-year-old Caucasian male patient with bilateral tophaceous gout to his knees involving the soft tissue and ulcerating skin breakdown to his left knee after an acute traumatic injury. Plain radiographs of the bilateral knees revealed large soft tissue masses anterior to the patella. Magnetic resonance imaging of the left knee was also performed which demonstrated heterogeneous masses consistent with tophi and peripheral enhancement with central necrosis. A diagnostic biopsy was performed to rule out malignancy the results confirmed gouty tophi. We report this case to note the atypical presentation of this disease. CONCLUSION: Chronic tophaceous gout presenting with ulcerating skin breakdown overlying a fungating tophaceous mass is uncommon considering the current availability of effective pharmaceutical treatments for hyperuricemia. Surgical intervention for tophaceous gout is seldom required and is traditionally reserved for atypical cases that present with deformities, severe pain, and joint destruction. Although ulcerative tophi are rare, they can have significant morbidity and greatly impact patients' quality of life. Surgical intervention was indicated in our patient to excise the mass and avoid infective complications.

Apalutamide for the Treatment of Nonmetastatic Castration-Resistant Prostate Cancer.

Prostate cancer is the fourth leading cause of cancer in the United States. Treatment of this oncologic disease involves a variety of different modalities including surgery, radiation, and systemic therapy. Systemic therapy is used for locally advanced and metastatic disease, and primarily involves hormonal blockade as a mechanism of disease control. Apalutamide is a nonsteroidal androgen receptor inhibitor that binds directly to the androgen receptor ligand binding-domain to prevent androgen receptor translocation. This agent is used in combination with gonadotropin-releasing hormone antagonists to shut down the production of testosterone through the reproductive system. It is the first drug to receive U.S. Food & Drug Administration approval for the treatment of nonmetastatic, castration-resistant prostate cancer. This article reviews the pharmacology of apalutamide along with its current place in therapy and management of associated adverse events.

Interhemispheric collaboration during digit and dot number-matching in younger and older adults.

Digit and dot number-matching stimuli were used to replicate findings reported for younger adults by Patel and Hellige (2007) and to explore whether performance would differ for younger versus older participants. Participants were to make numerical matches of digits only, dots only, and digits and dots mixed conditions to determine whether reaction time (RT), percentage error, and efficiency scores that combine latency and accuracy for match trials were better on within- versus across-hemisphere trials. Sixty-six younger and 42 older participants were screened with the Mini-Mental State Examination (MMSE) and the Geriatric Depression Scale. They performed the three experimental conditions and were assessed with Digit Span Forward and Backward subscales from the Wechsler Adult Intelligence Scale-III. Results for younger adults demonstrated a within-hemisphere advantage for the Digits and Mixed conditions and an across-hemisphere advantage for the Dots condition, consistent with previous literature. Older participants showed a stronger within-hemisphere advantage for the Digits condition compared with younger participants and no advantage for within- or across-hemisphere processing for the Mixed condition when RT was considered, but they performed similarly to younger adults when efficiency scores were used and showed a relative across-hemisphere advantage for the Dots condition. Although RT suggests age-related differences in how information is distributed across the hemispheres of the brain, more comprehensive efficiency scores indicate that younger and older adults appear to use similar strategies in the coordination of interhemispheric transfer of information. MMSE scores regardless of age were related to type of task but not to across- versus within-hemisphere performance.

Benefits of interhemispheric collaboration can be eliminated by mixing stimulus formats that involve different cortical access routes.

Previous studies indicate that the benefits of dividing an information processing load across both cerebral hemispheres outweigh the costs of interhemispheric transfer as tasks become more difficult or cognitively complex. This is demonstrated as better performance when two stimuli to be compared are presented one to each visual field and hemisphere than when both stimuli are presented to the same single hemisphere (an across-hemisphere advantage). Two experiments indicate that this finding does not generalize to complex tasks that require matching numeric quantities represented by two very different visual formats whose processing involves somewhat different cortical areas: digits and dice-like dot patterns. In fact, mixing these stimulus formats consistently produces a within-hemisphere advantage. We propose that, when two simultaneously presented stimuli are presented in sufficiently different visual formats, identification of the two stimuli may take place in parallel, via different cortical access routes and with little or no interference, even when they are presented to the same cerebral hemisphere.