Genetic drift and purifying selection shape within-host influenza A virus populations during natural swine infections.

Patterns of within-host influenza A virus (IAV) diversity and evolution have been described in natural human infections, but these patterns remain poorly characterized in non-human hosts. Elucidating these dynamics is important to better understand IAV biology and the evolutionary processes that govern spillover into humans. Here, we sampled an IAV outbreak in pigs during a week-long county fair to characterize viral diversity and evolution in this important reservoir host. Nasal wipes were collected on a daily basis from all pigs present at the fair, yielding up to 421 samples per day. Subtyping of PCR-positive samples revealed the co-circulation of H1N1 and H3N2 subtype swine IAVs. PCR-positive samples with robust Ct values were deep-sequenced, yielding 506 sequenced samples from a total of 253 pigs. Based on higher-depth re-sequenced data from a subset of these initially sequenced samples (260 samples from 168 pigs), we characterized patterns of within-host IAV genetic diversity and evolution. We find that IAV genetic diversity in single-subtype infected pigs is low, with the majority of intrahost Single Nucleotide Variants (iSNVs) present at frequencies of <10%. The ratio of the number of nonsynonymous to the number of synonymous iSNVs is significantly lower than under the neutral expectation, indicating that purifying selection shapes patterns of within-host viral diversity in swine. The dynamic turnover of iSNVs and their pronounced frequency changes further indicate that genetic drift also plays an important role in shaping IAV populations within pigs. Taken together, our results highlight similarities in patterns of IAV genetic diversity and evolution between humans and swine, including the role of stochastic processes in shaping within-host IAV dynamics.

Wide-Awake Local Anesthesia for a Proximal Humerus Fracture: A Case Report.

Introduction: Over the past two decades, wide-awake local anesthesia no-tourniquet (WALANT) surgery has gained substantial popularity, challenging conventional assumptions regarding the safety of epinephrine. This report investigates the unprecedented expansion of the wide-awake local anesthesia technique beyond hand surgeries. It meticulously documents its successful application in a peri-implant proximal humerus fracture, presenting a fresh perspective on its safety and viability for managing intricate orthopedic injuries. Case Report: The subject of this study is a 61-year-old HIV-positive male with a history of recurrent falls, seeking treatment for a peri-implant proximal humerus fracture. Electing the wide-awake local anesthesia option due to financial constraints, the patient underwent a successful surgery. The technique employed involved precise administration of local anesthetic, facilitating fracture reduction, and plate replacement. Notably, the emphasis was placed on active patient participation during intraoperative assessment. Conclusion: This report extends the recognized utility of WALANT surgery beyond hand surgeries, demonstrating its versatility and potential transformative impact on health-care delivery. The study underscores the pivotal role played by wide-awake local anesthesia surgery in addressing challenges related to health-care accessibility. It presents a promising avenue for future orthopedic interventions and positions itself as a safe and viable option for patients in underserved areas globally.

Restoring Functionality: Humeroradial Total Elbow Revision for Salvaging Total Elbow Arthroplasty Failure and Ulnar Bone Loss.

As the number of total elbow arthroplasty (TEA) continues to increase worldwide, one might predict the number of revision TEA would rise as well. The most common indications for revision TEA include (a) loosening, (b) infection, and (c) periprosthetic fracture. Although the rate of revision TEA procedures continues to rise due to the infrequency in which they are performed compared to other arthroplasty surgeries, no gold standard algorithm or procedure for managing severe ulnar bone loss in revision TEA has been determined. Various surgical techniques and strategies including allograft-prosthesis composite, custom long prosthesis with or without allograft, and resection arthroplasty have all been employed in attempting to address severe ulnar bone loss in revision TEA. Though the reported outcomes are mixed at best between each treatment strategy with similar complication rates. Another option is implanting the ulnar component into the radius. In those patients with severe ulnar bone loss, a humeroradial TEA revision can provide stability, restore range of motion, and provide pain relief.

Assessing osteoporosis screening compliance in total joint surgery: a retrospective chart review.

CONTEXT: Osteoporosis is a prevalent concern, particularly among aging populations, leading to increased risk of fractures, including those related to hip and knee arthroplasty procedures. Screening for osteoporosis, especially with dual X-ray absorptiometry (DXA) scans, is crucial for early detection and management. OBJECTIVES: This study aimed to assess adherence to osteoporosis screening guidelines among patients aged 65 and older undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) within a single health network. Factors influencing screening adherence were also explored. METHODS: A retrospective chart review of 2,160 patients undergoing elective THA or TKA between January 2019 and January 2023 was conducted. Demographic data, osteoporosis screening status, and occurrence of periprosthetic fractures were analyzed. Statistical analysis included descriptive statistics and chi-square tests. RESULTS: Only 24.1 % of eligible patients underwent a DXA scan prior to surgery. Females were more likely to undergo screening than males, and race was also associated with screening status. A total of 45 periprosthetic fractures were identified, with no significant correlation between osteoporosis status, DXA screening, and fracture occurrence. CONCLUSIONS: Adherence to osteoporosis screening guidelines among geriatric patients undergoing elective total joint arthroplasty remains low within the studied health network. Despite the lack of correlation between screening and fracture occurrence in this study, the importance of screening and potential optimization in high-risk patients is emphasized. Further research is needed to assess outcomes associated with different care pathways in bone health screening and management for elective geriatric total joint patients.

Salvage Treatment for a Periprosthetic Humeral Nonunion: A Case Report.

The patient, a 69-year-old female, presented one year after receiving a total elbow arthroplasty with a nonunion periprosthetic fracture of the humerus. Due to the patient's severe osteoarthritis of the ipsilateral shoulder and significant humeral deformity, a procedure linking the total elbow arthroplasty to the reverse shoulder implant via a cemented allograft-composite linkage sleeve was performed. Previous literature suggests upper extremity salvage surgery using large-scale allografts is successful in treating large tumor or infection-derived defects, though data is lacking as to whether this treatment is effective in periprosthetic fractures in patients with significant comorbidities. This patient's success in the postoperative year supports the use of allograft-composite reconstruction followed by linkage to a reverse shoulder implant as a salvage treatment for periprosthetic fractures under certain conditions, such as multiple adjacent implants, bone deformity, and severe osteoarthritis.

Transparency Matters: Assessing Harms Reporting Compliance in Randomized Controlled Trials Underpinning the AAOS Clinical Practice Guideline for Anterior Cruciate Ligament Injuries.

BACKGROUND: The American Academy of Orthopaedic Surgeons (AAOS) has developed a clinical practice guideline (CPG) for management of anterior cruciate ligament (ACL) injuries. Primary studies such as randomized controlled trials (RCTs) are cited as evidence for the guidelines. Given the influence that these trials have on patient care, adherence to standardized protocols for conducting and reporting RCTs is essential. PURPOSE: To evaluate the CONSORT (Consolidated Standards of Reporting Trials) Extension for Harms-related reporting of RCTs cited as supporting evidence for the AAOS CPG on the management of ACL tears. STUDY DESIGN: Cross-sectional study. METHODS: The reference section of the AAOS guideline for ACL tears was first screened for RCTs cited in the CPG. Next, each RCT was evaluated for adherence to the CONSORT Extension for Harms checklist. Both identification of RCTs and assessment of adherence were performed in a masked and duplicate process. Descriptive statistics were used to summarize adherence to CONSORT Extension for Harms items. A Pearson correlation test was conducted to assess the relationship between the year of publication and adherence to CONSORT harms reporting. RESULTS: The sample included 113 RCTs, of which 16 (14.2%) were published before the CONSORT Extension for Harms was implemented in 2004. Sample sizes ranged from 24 to 4564 participants, with a mean of 228. None of the included RCTs included all 18 items in the CONSORT Extension for Harms checklist. The mean number of checklist items reported was 4 (of 18; 22.2%). A moderate, positive, and statistically significant correlation was found between the RCT publication year and the adherence with reporting of the CONSORT Extension for Harms (t111 = 3.54; P < .001) (r = 0.32; 95% CI, 0.14-0.47). CONCLUSION: Harms were infrequently reported in RCTs cited as supporting evidence in the AAOS CPG for the management of ACL tears. One encouraging finding was the positive correlation between the year when RCTs were published and how well they adhered to reporting harms. Efforts to improve adverse event reporting are warranted, as RCTs are commonly used to make clinical decisions in orthopaedic surgery.