Relationship Between Perioperative Regional Anesthesia and the Risk of Missing Acute Compartment Syndrome Following Tibia Fractures.

BACKGROUND: The aim of this study was to determine the incidence of missed compartment syndrome in tibia fractures treated with and without regional anesthesia. METHODS: A retrospective chart review was performed of patients with operative tibial shaft or plateau fractures at a single level-one trauma hospital between January 2015 and April 2022 with a minimum of 3-month follow-up. Patients under 18 years of age, an ipsilateral knee dislocation, known neurologic injury at presentation, or prophylactic fasciotomy were excluded. We defined missed acute compartment syndrome (ACS) as a postinjury motor deficit still present at the 3-month postoperative appointment. For patients that received a peripheral nerve block, we recorded whether a continuous perineural catheter or one-time single-shot injection was performed, and the number of nerves blocked. Incidence rates for ACS were calculated with exact binomial 95% confidence intervals (CIs). Morphine milligram equivalents (MMEs) consumed 24 hours after surgery, use of nerve block, nerve block timing, and type of block were compared using Mann-Whitney and Kruskal-Wallis nonparametric tests. Statistical significance was defined as P < .05. RESULTS: The incidence of compartment syndrome diagnosed and treated during index hospitalization was 2.2% (17/791, 95% CI, 1.3%-3.4%). The incidence of missed ACS was 0.9% (7/791, 95% CI, 0.4%-1.8%). The incidence of missed ACS was not different between those who received nerve block 0.7% (4/610, 95% CI, 0.2%-1.7%), and those who did not (1.7% (3/176, 95% CI, 0.4%-4.8%) P = .19). Within patients receiving a nerve block, all patients with missed ACS (n = 4) received a perineural catheter. Similar missed ACS rates were observed between tibial shaft and plateau fractures. Patients receiving a nerve block had lower MME compared to those who did not receive a nerve block (P < .001). CONCLUSIONS: The results do not provide evidence that perioperative regional anesthesia increases the incidence of missed ACS in patients with operative tibial shaft or plateau injuries. but does decrease postoperative opioid requirements.

A Systematic Review of Patient Selection Criteria for Outpatient Total Shoulder Arthroplasty.

The utilization of total shoulder arthroplasty (TSA) is increasing, driving associated annual health care costs higher. Opting for outpatient over inpatient TSA may provide a solution by reducing costs. However, there is no single set of accepted patient selection criteria for outpatient TSA. Here, the authors identify and systematically review 14 articles to propose evidence-based criteria that merit postoperative admission. Together, the studies suggest that patients with limited ability to abmluate independently or a history of congestive heart failure may benefit from postoperative at least one night of hospital based monitoring and treatment.

Can You Pay Your Way to Readership? Free to Publish Open Access Formats Receive Greater Readership and Citations Than Paid Open Access Formats in Total Knee Arthroplasty Literature.

BACKGROUND: As publishing with open access is becoming increasingly popular within orthopaedics, understanding the types of publishing options available and what each may deliver is critically important. Hybrid articles require a high article processing charge. Open journal articles have a lower fee, while closed license articles are freely accessible at no charge. Open repository articles are peer-reviewed manuscripts posted freely online. The purpose of this study was to determine the relationship between article type and resulting citations, social media attention, and readership in total knee arthroplasty (TKA) literature. METHODS: Open access TKA journal articles published since 2016 were found using the Altmetric Explorer Database. Data gathered included the Altmetric Attention Score (attention), Mendeley Readership Score (readership), and citations per article. Articles were grouped by type: open journal, hybrid, closed license, and open repository. Results were analyzed using descriptive statistics and Tukey's analysis; α = 0.05. RESULTS: A total of 9,606 publications were included. The open repository had the greatest mean citations (14.40), while open journal (9.55) had fewer than all other categories (P < .001). Hybrid had the greatest mean attention (10.35), and open journal (6.16) had a lower mean attention than all other categories (P ≤ .002). Open repository had the greatest mean readership (44.68), and open journal (34.00) had a lower mean readership than all other categories (P ≤ .012). The mean publication fee for paid publication options was $1,792 United States dollars. CONCLUSIONS: In open access TKA literature, free-to-publish open repositories had the greatest mean citations and readership. Free publication options, open repositories and closed licenses, had greater readership compared to paid publication options.

Image Rotation Alters Apparent Fibula Length: An Evaluation of Talocrural Angle, Shenton Line, and Dime Sign.

BACKGROUND: Fibula shortening can compromise ankle stability and force transmission, thereby impacting clinical outcomes. Because radiographs depict 3-dimensional anatomy in 2 dimensions, accurate radiographic assessment of fibula length is a commonly encountered clinical challenge. The talocrural angle (TCA), Shenton line, and dime sign are useful parameters of fibula length. Yet, the impact of 3-dimensional limb positioning on these radiographic parameters is not established. METHODS: Bone models were constructed from CT scans of 30 lower limbs. Fibula length was computationally manipulated, and digitally reconstructed radiographs were generated reflecting 1-degree increments of sagittal and axial plane rotation of each limb for each fibula length condition. The TCA was computationally measured on each image. The presence of an aligned mortise view, intact Shenton line, and intact dime sign was assessed by 2 observers. RESULTS: The mean TCA, which was 78.0 (95% CI ± 1.6) degrees for a true mortise projection with anatomic fibula length, changed by approximately 1 degree per millimeter of fibula length change. On average, 14.7 degrees of caudal rotation obscured 2 mm of fibular shortening by virtue of producing the same TCA as a true mortise view with anatomic fibula length, designated a false positive view. Axial rotation had a comparatively small effect. Observers 1 and 2 were, respectively, 91% and 88% less likely to accurately judge the image alignment of the false positive images compared to true mortise images. Moreover, intraobserver agreement was poor to moderate (mean 0.47, range 0.13-0.59) and interobserver agreement was uniformly poor (mean 0.08, range 0.01-0.20). CONCLUSION: In our study using digitally reconstructed radiographs from CT scans of 30 limbs, we found that sagittal plane rotation impacts the radiographic appearance of fibula length as measured by the TCA. Limb axial rotation had a comparatively small effect. Further study of human perception of Shenton line and dime sign is needed before the effect of rotation on these parameters can be fully understood. LEVEL OF EVIDENCE: Level IV, case series.

Genomic subtypes of cutaneous melanoma have distinct metabolic profiles: A single-cell transcriptomic analysis.

OBJECTIVE: Genomic profiling previously classified melanoma into distinct subtypes based on the presence or absence of mutations in driver genes, but metabolic differences between and within these groups have yet to be thoroughly analyzed. Thus, the objective of the present study is to provide the first effort to holistically characterize the metabolic landscape of qualified melanoma genomic subtypes at single-cell resolution. METHODS: Expression data for a total of 1145 malignant cells sourced from NRAS(Q61L), BRAF(V600E), and NRAS/BRAF WT melanomas were retrieved from the Broad Single Cell Portal. Metabolic activity was interrogated by pathway scoring and gene set enrichment analysis. RESULTS: A total of 53 metabolic pathways were differentially regulated in at least one melanoma genomic subtype. Some notable findings include: BRAF/NRAS WT cells were enriched for fatty acid biosynthesis and depleted for metabolism of alanine, aspartate, and glutamate; BRAF(V600E) melanoma cells were enriched for beta-alanine metabolism and depleted for phenylalanine metabolism; NRAS(Q61L) melanoma cells were enriched for steroid biosynthesis and depleted for linoleic acid metabolism. CONCLUSION: Primary limitations include the total quantity of single cells and breadth of available genomic subtypes plus inherent noisiness of the applied methodologies. Nonetheless, these findings nominate novel, testable therapeutic targets.

Primary and Metastatic Cutaneous Melanomas Discriminately Enrich Several Ligand-Receptor Interactions.

INTRODUCTION: Cutaneous melanoma remains a leading cancer with sobering post-metastasis mortality rates. To date, the ligand-receptor interactome of melanomas remains weakly studied despite applicability to anti-cancer drug discovery. Here we leverage established crosstalk methodologies to characterize important ligand-receptor pairs in primary and metastatic cutaneous melanoma. METHODS: Bulk transcriptomic data, representing 470 cutaneous melanoma samples, was retrieved from the Broad Genome Data Analysis Center Firehose portal. Tumor and stroma compartments were computationally derived as a function of tumor purity estimates. Identification of preferential ligand-receptor interactions was achieved by relative crosstalk scoring of 1380 previously established pairs. RESULTS: Metastatic cutaneous melanoma uniquely enriched PTH2-PTH1R for tumor-to-stroma signaling. The Human R-spondin ligand family was involved in 4 of the 15 top-scoring stroma-to-tumor interactions. Receptor ACVR2B was involved in 3 of the 15 top-scoring tumor-to-tumor interactions. CONCLUSIONS: Numerous gene-level differences in ligand-receptor crosstalk between primary and metastatic cutaneous melanomas. Further investigation of notable pairings is warranted.

Minimally Invasive Procedures, Perioperative Telemedicine, and Decreased Hospital Stays Following Covid-19 Surgical Restrictions: Spinal Surgery.

The 2019 severe acute respiratory syndrome coronavirus 2 pandemic had devastating impacts on healthcare system operations. Disruption of this delicate system led to international healthcare challenges with new policy changes that affected all specialties, including the global spine surgery community. The pandemic disrupted normal spine surgery proceedings, restricting, and postponing elective procedures, which comprise a large proportion of spine surgeries. This disruption may have contributed to significant economic losses for providers and resulted in the prolonged impairment of patients who were forced to postpone their procedures. However, response to the pandemic precipitated new procedural guidelines and practices that prioritize health outcomes and satisfaction. These new changes and innovations are positioned to provide lasting economic and procedural impacts in favor of both providers and patients. Thus, the objective of our review is to explore how spinal surgical practices and post-op recovery changed following COVID-19 and highlight some lasting impacts the pandemic created for future patients.

Omics analysis of uveal melanoma: Leukocyte gene signatures reveal novel survival distinctions and indicate a prognostic role for cytolytic activity scoring.

Objective: The significant metastatic potential of uveal melanoma (UVM) lends to high mortality. Even with successful local tumor treatment, many patients will develop metastatic disease. The present study aims to elucidate the relationship between tumor-infiltrating immune cell (TIIC) diversity and survival to identify potential therapeutic targets and improve UVM prognosis. Methods: Bulk deconvolution was used to determine the relative proportions of 22 hematopoietic TIIC from 80 UVM tumor samples. Cytolytic activity (CYT) was determined, and associated survival probabilities were mined using time-to-event data. Nominal P-values were subjected to FDR correction. Results: High relative abundance of tumor-infiltrating naïve B cells, resting memory CD4+ T cells, and monocytes correlated with better overall and disease-free survival probability. Low relative abundance of CD8+ T cells correlated with better overall survival and disease-free survival probability. CYT correlated positively with relative abundance of naïve B cells, resting memory CD4+ T cells, and monocytes. CYT correlated negatively with relative abundance of CD8+ T cells. Conclusion: Infiltrating naïve B cells, resting memory CD4+ T cells, monocytes, and CD8+ T cells are potential therapeutic targets in UVM that warrant further investigation. High CYT estimates associate with worse UVM survival outcomes.