Same-day discharge is not inferior to longer length of in-hospital stay for 90-day readmissions following shoulder arthroplasty.

BACKGROUND: Shoulder arthroplasty is a common orthopedic procedure, performed historically in the inpatient setting. However, interest in same-day discharge has increased. We sought to evaluate 90-day readmission, 90-day emergency department (ED) visit, 90-day deep infection, 90-day venous thromboembolism (VTE), and 1-year mortality after same-day shoulder arthroplasty compared with an inpatient stay. METHODS: We conducted a retrospective cohort study using data from an integrated health care system's Shoulder Arthroplasty Registry. A total of 6503 elective primary unilateral total shoulder and reverse total shoulder arthroplasties performed between 2005 and 2016 were included; 405 (6%) had same-day discharge. The likelihood of 90-day events, including readmission, ED visit, deep infection, and VTE, and 1-year mortality after same-day discharge was compared with 1- to 4-night inpatient stay using generalized estimating equations with noninferiority testing, adjusting for age, sex, body mass index, race, American Society of Anesthesiologists classification, select comorbidities, osteoarthritis, anesthesia type, procedure type, and surgeon effect. RESULTS: We failed to observe a difference between same-day discharge and 1- to 4-night stay in terms of 90-day readmission, 90-day ED visit, and 1-year mortality. Same-day discharge was not inferior to 1- to 4-night stay regarding 90-day readmission, but we did not have evidence to support noninferiority for 90-day ED visits or 1-year mortality. Ninety-day deep infections and VTE were too infrequent for adjusted analysis. CONCLUSIONS: We found same-day shoulder arthroplasty not to be inferior to an inpatient stay for 90-day readmission. Future investigation into the reasons for readmission and ED visit after same-day shoulder arthroplasty and interventions to mitigate these adverse events is needed.

Tread carefully: A functional variant in the human NADPH oxidase 4 (NOX4) is not disease causing.

In this study, we report a paediatric patient with a lethal phenotype of respiratory distress, failure to thrive, pancreatic insufficiency, liver dysfunction, hypertrophic cardiomyopathy, bone marrow suppression, humoral and cellular immune deficiency. To identify the genetic basis of this unusual clinical phenotype and potentially make available the option of future prenatal testing, whole exome sequencing (WES) was used followed by functional studies in a bid to confirm pathogenicity. The WES we identified a homozygous novel variant, AK298328; c.9_10insGAG; p.[Glu3dup], in NOX4 in the proband, and parental heterozygosity for the variant (confirmed by Sanger sequencing). NADPH Oxidase 4 NOX4 (OMIM 605261) encodes an enzyme that functions as the catalytic subunit of the NADPH oxidase complex. NOX4 acts as an oxygen sensor, catalysing the reduction of molecular oxygen, mainly to hydrogen peroxide (H2O2). However, although, our functional data including 60% reduction in NOX4 protein levels and a 75% reduction in the production of H2O2 in patient fibroblast extracts compared to controls was initially considered to be the likely cause of the phenotype in our patient, the potential contribution of the NOX4 variant as the primary cause of the disease was clearly excluded based on following pieces of evidence. First, Sanger sequencing of other family members revealed that two of the grandparents were also homozygous for the NOX4 variant, one of who has fibromuscular dysplasia. Second, re-evaluation of more recent variant databases revealed a high allele frequency for this variant. Our case highlights the need to re-interrogate bioinformatics resources as they are constantly evolving, and is reminiscent of the short-chain acyl-CoA dehydrogenase deficiency (SCADD) story, where a functional defect in fatty acid oxidation has doubtful clinical ramifications.

Projected shifts in loggerhead sea turtle thermal habitat in the Northwest Atlantic Ocean due to climate change.

It is well established that sea turtles are vulnerable to atmospheric and oceanographic shifts associated with climate change. However, few studies have formally projected how their seasonal marine habitat may shift in response to warming ocean temperatures. Here we used a high-resolution global climate model and a large satellite tagging dataset to project changes in the future distribution of suitable thermal habitat for loggerheads along the northeastern continental shelf of the United States. Between 2009 and 2018, we deployed 196 satellite tags on loggerheads within the Middle Atlantic Bight (MAB) of the Northwest Atlantic continental shelf region, a seasonal foraging area. Tag location data combined with depth and remotely sensed sea surface temperature (SST) were used to characterize the species' current thermal range in the MAB. The best-fitting model indicated that the habitat envelope for tagged loggerheads consisted of SST ranging from 11.0° to 29.7 °C and depths between 0 and 105.0 m. The calculated core bathythermal range consisted of SSTs between 15.0° and 28.0 °C and depths between 8.0 and 92.0 m, with the highest probability of presence occurred in regions with SST between 17.7° and 25.3 °C and at depths between 26.1 and 74.2 m. This model was then forced by a high-resolution global climate model under a doubling of atmospheric CO2 to project loggerhead probability of presence over the next 80 years. Our results suggest that loggerhead thermal habitat and seasonal duration will likely increase in northern regions of the NW Atlantic shelf. This change in spatiotemporal range for sea turtles in a region of high anthropogenic use may prompt adjustments to the localized protected species conservation measures.

Riders on the storm: loggerhead sea turtles detect and respond to a major hurricane in the Northwest Atlantic Ocean.

BACKGROUND: Extreme weather events, including hurricanes, have considerable biological, ecological, and anthropogenic impacts. Hurricane Irene caused substantial economic damage when it hit the Mid-Atlantic Bight (MAB) off of the eastern United States in August of 2011. The MAB is highly stratified during the summer when a strong thermocline separates warm, surface water from deep, cold water, and this oceanographic phenomenon makes modeling hurricane strength difficult. Loggerhead sea turtles (Caretta caretta) forage in the MAB primarily during the stratified season and their dive behavior to the bottom allows them to experience the oceanographic conditions of the entire water column. METHODS: In this study, we analyzed the movements and dive behavior of juvenile and adult-sized loggerhead sea turtles (n = 18) that were foraging in the MAB as Hurricane Irene moved through the region. The satellite tags deployed on these turtles transmitted location data and dive behavior as well as sea surface temperature (SST) and temperature-depth profiles during this time. RESULTS: Behavioral and environmental shifts were observed during and after the hurricane compared to conditions before the storm. During the hurricane, most of the turtles (n = 15) moved north of their pre-storm foraging grounds. Following the storm, some turtles left their established foraging sites (n = 8) moving south by 7.3-135.0 km, and for the others that remained (n = 10), 12% of the observed dives were longer (0.54-1.11 h) than dives observed before the storm. The in situ data collected by the turtle-borne tags captured the cooling of the SST (Mean difference = 4.47°C) and the deepening of the thermocline relative to the pre-storm conditions. CONCLUSIONS: Some of the loggerhead behavior observed relative to a passing hurricane differed from the regular pattern of seasonal movement expected for turtles that forage in the MAB. These data documented the shifts in sea turtle behavior and distribution during an ecosystem-level perturbation and the recorded in situ data demonstrated that loggerheads observe environmental changes to the entire water column, including during extreme weather events.

Life-history constraints on maximum population growth for loggerhead turtles in the northwest Atlantic.

Conservation planning for protected species often relies on estimates of life-history parameters. A commonly used parameter is the instantaneous maximum population growth rate (r max) that can be used to limit removals and design recovery targets. Estimation of r max can be challenging because of limited availability of species- and population-specific data and life-history information. We applied a method proposed by Neil and Lebreton, originally developed for birds, to loggerhead turtles. The method uses age-at-first-reproduction and adult survival to estimate r max. We used a variety of datasets and matrix population models to confirm an allometric assumption required by the method, and to generate estimates of age-at-first-reproduction and adult survival. A meta-analysis was applied to parameters from reported growth curves, which were then combined with the size distribution of neophyte nesters to derive estimates of age-at-first-reproduction. Adult survival rates were obtained from an existing matrix population model. Monte Carlo simulation was then used to combine the estimates of the allometric coefficients, age-at-first-reproduction, and adult survival to obtain a probability distribution of approximate r max values. Estimated annual maximum population growth rates averaged 0.024, with a mode of 0.017 and a 95% highest density interval of 0.006-0.047. These estimates were similar to values reported by others using different methods and captured the variability in positive, annual change estimates across nesting beach sites for the northwest Atlantic loggerhead population. The use of life-history parameters has a long history in wildlife and fisheries management and conservation planning. Our estimates of r max, while having some biases and uncertainty, encompassed values presently used in recovery planning for loggerhead turtles and offer additional information for the management of endangered and threatened species.

Impact of Image-Derived Instrumentation on Total Knee Arthroplasty Revision Rates: An Analysis of 83,823 Procedures from the Australian Orthopaedic Association National Joint Replacement Registry.

BACKGROUND: Computer navigation and image-derived instrumentation (IDI) are technology-based methods developed to improve outcomes and potentially reduce revision total knee arthroplasty (TKA). IDI refers to the use of manufactured, patient-specific surgical jigs. Conflicting reports exist on IDI-associated improvements in outcomes. The primary aim of the current study was to compare the rates of revision among TKA cases in which components were initially implanted with use of IDI, computer navigation, or neither of these methods ("other" TKA). The secondary aim was to determine whether the outcomes of IDI differed for specific subgroups. METHODS: Data were obtained from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) for the 3 TKA groups: IDI, computer-navigated, and other TKA. The study period was from the first IDI procedure recorded by the AOANJRR (April 2010) to December 31, 2016. The analysis was restricted to primary TKA cases undertaken for osteoarthritis and involving patellar resurfacing and the use of a cross-linked polyethylene insert. Subanalyses were performed to evaluate the effects of age, sex, implantation method, IDI manufacturer, prosthetic design, and prosthesis type on the rates of revision. Kaplan-Meier estimates of survivorship described the time to first revision. Hazard ratios (HRs, Cox proportional hazards models) with adjustment for age and sex were used to compare revision rates. RESULTS: IDI was used in 5,486 primary TKA procedures. There was no significant difference among the groups in the cumulative percent revision (CPR) at 5 years: 3.3% (95% confidence interval [CI], 2.4% to 4.6%) for IDI, 2.4% (95% CI, 2.2% to 2.7%) for the computer-navigated group, and 2.5% (95% CI, 2.3% to 2.7%) for other TKA. Posterior-stabilized TKA with use of the IDI method had a significantly higher rate of revision at >3 months (HR, 1.45 [95% CI, 1.02 to 2.04]; p = 0.036), as did IDI TKA in the ≤65-year-old patient cohort (HR, 1.52 [95% CI, 1.10 to 2.09]; p = 0.010), compared with computer-navigated TKA. Patellar revision was significantly more likely in the IDI group. CONCLUSIONS: IDI TKA demonstrated no overall difference in early to mid-term revision rates compared with standard implantation methods. However, elevated rates of revision were seen with posterior-stabilized TKA, in patients ≤65 years of age, and for patellar revision, meaning that this method should be used with some caution and requires further study. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outpatient Total Shoulder Arthroplasty Does Not Increase the 90-Day Risk of Complications Compared With Inpatient Surgery in Prescreened Patients.

Outpatient total joint arthroplasty is becoming a more attractive option for hospitals, surgeons, and patients. In this study, the authors evaluated the safety of outpatient shoulder arthroplasty by comparing an outpatient cohort with an inpatient cohort. Ninety-day outcomes of consecutively performed elective shoulder arthroplasty cases from 2012 to 2016 were retrospectively reviewed. Patients were preoperatively assigned to outpatient or inpatient care. Primary outcomes were emergency department visits, readmissions, mortality, and surgical morbidity within 90 days of surgery. Two-tailed t tests were used to evaluate differences. Bivariate and multivariate logistic regressions were used to determine if the odds of emergency department visit, readmission, or complications were significantly different between the cohorts. There were 118 outpatient and 64 inpatient shoulder arthroplasty procedures. Mean age and American Society of Anesthesiologists score were lower in the outpatient group compared with the inpatient group-68.1 vs 72.4 years (P=.01) and 2.3 vs 2.6 (P<.01), respectively. In the multivariate logistic regression model including all arthroplasty cases, the odds of outpatient to inpatient readmission was significantly different (odds ratio, 0.181; P=.027). However, when only total shoulder arthroplasty cases were included, no difference was detected. No statistically significant difference was noted for number of emergency department visits, mortality, or surgical morbidity within 90 days of surgery in any of the models. There was 1 death in the ambulatory group at 28 days after surgery. On the basis of these findings, the authors believe that, for carefully selected patients, an outpatient shoulder arthroplasty protocol is safe when compared with inpatient protocols. [Orthopedics. 2018; 41(4):e563-e568.].

Evaluation of tendon graft fixation using alpha-BSM calcium phosphate cement.

PURPOSE: Many ligament reconstruction procedures require tendon healing within a surgically prepared bone tunnel. The interface between the graft and tunnel wall is the "weak link" in the initial phase of this process. By providing additional fixation and serving as a carrier for bone-derived growth factors, calcium phosphate cements may augment healing. The purpose of this study was to evaluate alpha-BSM calcium phosphate cement as the sole method of fixation for tendon and bone-tendon-bone grafts in an in vitro porcine model. METHODS: Ten tendon grafts and ten bone-tendon-bone grafts were fixed within porcine femoral and tibial bone tunnels by use of alpha-BSM calcium phosphate cement. The grafts were then loaded to failure. The ultimate pullout strength and the site of failure were recorded for each specimen. RESULTS: The bone-tendon-bone grafts achieved a mean pullout strength of 224.8 N (+/-79.9 N). Of the grafts, 6 failed at the cement-bone plug interface, 2 failed because of fracture of the bone plug, and 2 failed at the tendon-bone plug interface. The tendon grafts had a mean load to failure of 81.2 N (+/-23.7 N), and all 10 failed at the tendon-cement interface. The difference in fixation strength between these graft types was significant (P < .05). CONCLUSIONS: Though inadequate as the sole means of graft fixation, alpha-BSM calcium phosphate cement can help to augment bone plug fixation during the early phase of tendon-bone healing. In addition, alpha-BSM may provide added graft fixation and increased stiffness and act as a growth factor carrier for both tendon grafts and bone-tendon-bone grafts in ligament reconstruction surgery. CLINICAL RELEVANCE: This study evaluated the ability of alpha-BSM cement to augment tendon-bone healing because it may play a role as a growth factor carrier in future tendon healing models.

A comparison between traditional and measurement-error growth models for weakfish Cynoscion regalis.

Inferring growth for aquatic species is dependent upon accurate descriptions of age-length relationships, which may be degraded by measurement error in observed ages. Ageing error arises from biased and/or imprecise age determinations as a consequence of misinterpretation by readers or inability of ageing structures to accurately reflect true age. A Bayesian errors-in-variables (EIV) approach (i.e., measurement-error modeling) can account for ageing uncertainty during nonlinear growth curve estimation by allowing observed ages to be parametrically modeled as random deviates. Information on the latent age composition then comes from the specified prior distribution, which represents the true age structure of the sampled fish population. In this study, weakfish growth was modeled by means of traditional and measurement-error von Bertalanffy growth curves using otolith- or scale-estimated ages. Age determinations were assumed to be log-normally distributed, thereby incorporating multiplicative error with respect to ageing uncertainty. The prior distribution for true age was assumed to be uniformly distributed between ±4 of the observed age (yr) for each individual. Measurement-error growth models described weakfish that reached larger sizes but at slower rates, with median length-at-age being overestimated by traditional growth curves for the observed age range. In addition, measurement-error models produced slightly narrower credible intervals for parameters of the von Bertalanffy growth function, which may be an artifact of the specified prior distributions. Subjectivity is always apparent in the ageing of fishes and it is recommended that measurement-error growth models be used in conjunction with otolith-estimated ages to accurately capture the age-length relationship that is subsequently used in fisheries stock assessment and management.

Proximal humerus osteolysis after revision rotator cuff repair with bioabsorbable suture anchors.

Biodegradable anchors were designed to provide secure fixation while allowing for later resorption and replacement by host tissue. First-generation implants degraded relatively rapidly and caused foreign-body reactions, synovitis, fragmentation, and osteolysis. Newer implants have similar complications. It is not known if the primary cause of the osteolysis is biological (precipitated by breakdown products of the polymer) or mechanical (caused by initial loss of implant stability). Case reports have described glenoid osteolysis around biodegradable suture anchor placement for shoulder stabilization, but up until now, to our knowledge, only 1 case of proximal humerus osteolysis has been reported for these implants. Here we describe a semicrystalline, poly-L-lactic acid bioabsorbable suture anchor failure after revision rotator cuff repair with subsequent humeral tuberosity osteolysis.

MRI evaluation of isolated arthroscopic partial meniscectomy patients at a minimum five-year follow-up.

BACKGROUND: The risk of radiographic knee degeneration after partial or total meniscectomy is well documented, but no prior study has employed cartilage-sensitive MRI technology to assess degenerative changes after meniscectomy. HYPOTHESIS: Arthroscopic partial meniscectomy results in early articular cartilage wear and subchondral bony degeneration, even in the absence of clinical symptoms, and these findings can be evaluated with cartilage-sensitive MRI. STUDY DESIGN: Retrospective cohort. METHODS: Twenty-nine patients (ages: 15-40) who had undergone isolated arthroscopic partial medial or lateral meniscectomy with at least 5-year follow-up were evaluated. All patients had arthroscopically normal articular cartilage at the time of initial meniscectomy. Seventeen patients (18 knees) underwent partial medial meniscectomy (MM) and 12 patients underwent partial lateral meniscectomy (LM) with mean follow-up of 8.4 and 7.1 years, respectively. Follow-up evaluation included physical examination, outcome questionnaires, and cartilage-sensitive MRI examination with modified Outerbridge grading of articular surfaces. RESULTS: Outerbridge grades II-IV were noted in 64% of medial compartment joint surfaces in group MM knees versus 33% of lateral compartment joint surfaces in group LM knees. Abnormal cartilage surfaces (grades II-IV), subchondral sclerosis, and condylar squaring were all significantly more frequent after medial meniscectomy (p < 0.05). Groups MM and LM had no significant differences among outcome scores, which remained excellent in both groups. A significant negative correlation was found between the severity of cartilage wear and functional scoring in the MM group, suggesting that functional disability lags behind early MRI evidence of degeneration. CONCLUSIONS: Despite optimal preoperative prognostic factors and excellent functional outcomes, MRI evidence of early articular cartilage degeneration was present in both partial medial and lateral meniscectomy patients at a minimum 5-year follow-up. Results support the use of cartilage-sensitive MRI as a noninvasive screening technique to evaluate cartilage changes after arthroscopic partial meniscectomy and may help to counsel the high-risk patient in regard to postoperative activity.

Advances in the management of medial elbow pain in baseball pitchers.

Overhead-throwing athletes, particularly baseball pitchers, subject their elbows to tremendous amounts of valgus stress during the throwing motion. As a result of this stress, baseball pitchers are at considerable risk for injury. The proper functioning and stability of the elbow depends upon the bony articulations and soft tissue structures. The stresses placed across the elbow joint with repetitive throwing can lead to injury. Although the majority of injuries encountered are overuse injuries, acute injuries can also occur. Proper and timely diagnosis and treatment of these throwers is critical, to allow for the athlete's successful return to competition.