Trends and outcomes in the surgical management of young adults with knee osteoarthritis using high tibial osteotomy and unicompartmental knee arthroplasty.

INTRODUCTION: A significant portion of knee osteoarthritis is diagnosed in patients under the age of 55, where greater activity demands make total knee arthroplasty less desirable. High tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) are useful alternatives, but there is little understanding of which procedure is advantageous. Hence, this study examines the utilization, complication, and reoperation rates among the HTO vs. UKA in young patients with primary osteoarthritis. METHODS: A retrospective review of the National Surgical Quality Improvement Program was performed to identify 2318 patients < 55 years of age who received either a HTO or UKA for primary osteoarthritis between 2011 and 2021. Bivariate analyses compared preoperative and intraoperative characteristics among each procedure. Then, multivariate analyses examined if either procedure was associated with worse 30-day postoperative complications or need for reoperation, independent of the statistically significant pre- and intraoperative disparities. RESULTS: UKAs were performed 14.2 times more commonly than HTOs, and the patients selected for HTO were more likely to be younger, have a lower BMI, have the healthiest ASA Class score, and less likely to have hypertension requiring medication (p < 0.001). HTOs took 17.5% longer to perform and had a longer average length of stay (p < 0.001), while UKAs were more likely to be performed out-patient (p < 0.001). HTOs also had higher rates of serious complications (p = 0.02), overall complications (p = 0.004), and need for reoperation (p = 0.004). Multivariate modelling demonstrated that procedure type was not a predictor of serious complications, but the use of HTO was significantly associated with any complications (odds ratio = 3.63, p = 0.001) and need for reoperation (3.21, p = 0.029). CONCLUSION: Although healthier patients were selected for HTOs, UKAs were found to have a lower risk of complications and immediate reoperation. Additionally, UKAs had the advantage of lower operative burden, shorter length of stay, and a higher efficacy in outpatient settings.

Frailty and comorbidity predict 30 day postoperative outcomes, independent of anatomical site of fracture.

INTRODUCTION: Fragility fractures are a major threat to geriatric patients. However, it is unclear whether this patient population's inherent frailty and comorbidity or the physiologic insult caused by the fracture and its surgery contribute more to undesirable patient outcomes. Hence, this study examines if frailty and comorbidity can predict 30 day postoperative outcomes while the effects of multiple fracture sites are accounted for. METHODS: A retrospective review of patients ≥ 65 years of age in the National Surgical Quality Improvement Program who underwent surgical treatment between 2013 and 2017 was performed. A total of 52,497 patients were included in the final analysis, including fracture cases of the extremities, limbs, and hip. Demographics, several metrics of preoperative health, temporal variables, and fracture location were tested in bivariate analysis of 30 day postoperative mortality, length of stay in hospital, discharge outcome, and complications. Significant variables were considered for multivariate logistic regression models for each outcome. RESULTS: Frailty, comorbidity, and time to surgery were found to be the significant predictors in multivariate analysis of each 30 day postoperative outcome, independent of the effects of fracture site (p < 0.05). Examination of 30 day mortality found that American Society of Anesthesiologists Class ≥ 3 (2.30 Odds Ratio), modified Frailty Index > 0 (1.37 OR), Charleston Comorbidity Index ≥ 6 (1.63 OR), and time to surgery (1.45 OR) were especially important (all p < 0.05). Additionally, the worst outcomes were associated with fractures of the pelvis/hip and femur/knee, including 30 day mortality (5.90 and 5.12 OR, respectively; both p < 0.05). CONCLUSION: The effects of the preoperative health were found to be independent of patient demographics and fracture site. Additionally, specific high-risk fracture sites are significant predictors of outcome, supporting the need to prioritize these patients. Clinical care pathways for geriatric patients may benefit from emphasis on these high-risk fractures and preoperative patient health.

Physiologic Motion in the Intact and Unstable Syndesmosis During Plantigrade Weightbearing in Controlled Ankle Motion Boots.

Consensus has not been reached for the optimal postoperative care after high ankle sprain and syndesmotic fixation. A potential drawback of earlier return to activity is greater instability of the ankle and fixation failure. The controlled ankle motion (CAM) boot has been an effective implementation to stabilize the leg and may aid in safe early weightbearing status. However, there is insufficient study of its effect on motion in the syndesmosis following injury. Hence, the aim of this cadaveric study was to determine the stability of the ankle with a CAM boot at 3 levels of injury: syndesmosis ligaments intact (no injury), syndesmosis ligaments cut, and syndesmosis and fibula cut. Six cadaveric legs were subjected to each level of injury and axially loaded at 1 Hz between 100 N-1.5 times body weight for 50 seconds, and axial force, axial displacement, and optical tracking data were recorded. It was found that the ankle, when protected by the CAM boot, maintained syndesmosis motion with no difference (p > .05) from the uninjured state, regardless of syndesmotic ligament and fibular injury. This finding was consistent across anterior-posterior, medial-lateral, and superior-inferior axes. Overall, our study may suggest that early weightbearing with a CAM boot maintains a physiologically range of motion in the syndesmosis.

Nonphysician Evaluators and Recording-Based Tools in Surgical Skill Assessment: A Feasibility Study.

OBJECTIVES: To investigate the feasibility of nonmedically trained evaluators and image- and video-based tools in the assessment of surgical skills in a key orthopedic procedure. DESIGN: Orthopedic surgeons at varying skill levels were evaluated by their ability to repair a cadaveric bi-malleolar ankle fracture. Nonphysician viewers and expert orthopedic surgeons independently scored video recordings and fluoroscopy images of the procedure through Global Rating Scales (GRS) and procedure-specific checklist tools. Statistical analysis was used to determine if the evaluators and assessment tools were able to differentiate skill level. SETTING: An academic tertiary care hospital. PARTICIPANTS: The surgical procedure was completed by 3 orthopedic residents, 3 orthopedic trauma fellows, and 4 orthopedic trauma attending surgeons. The procedure was independently evaluated by 2 orthopedic surgeons and 2 nonphysicians. RESULTS: Operating participants were stratified by ≤ or >10 bimalleolar ankle fracture cases performed alone (inexperienced, n = 5 vs experienced, n = 5). Expert surgeon viewers could effectively stratify skill group through the GRS for video and fluoroscopy analysis (p < 0.05), and the video procedure-specific checklist (p < 0.05), but not the fluoroscopy procedure-specific checklist. Nonphysician viewers generally recognized skill groupings, although with less separation than surgeon viewers. These evaluators performed the best when aided by video and fluoroscopy procedure-specific checklists. Meanwhile, breakdowns of each tool into critical zones for improvement and evaluator-independent metrics such as case experience, self-reported confidence, and surgical time also indicated some skill differentiation. CONCLUSIONS: The feasibility of using video recordings and fluoroscopic imaging based surgical skills assessment tools in orthopedic trauma was demonstrated. The tools highlighted in this study are applicable to both cadaver laboratory settings and live surgeries. The degree of training that is required by the evaluators and the utility of measuring surgical times of specific tasks should be the subject of future studies.

The PAICE suite reveals circadian posttranscriptional timing of noncoding RNAs and spliceosome components in Mus musculus macrophages.

Circadian rhythms broadly regulate physiological functions by tuning oscillations in the levels of mRNAs and proteins to the 24-h day/night cycle. Globally assessing which mRNAs and proteins are timed by the clock necessitates accurate recognition of oscillations in RNA and protein data, particularly in large omics data sets. Tools that employ fixed-amplitude models have previously been used to positive effect. However, the recognition of amplitude change in circadian oscillations required a new generation of analytical software to enhance the identification of these oscillations. To address this gap, we created the Pipeline for Amplitude Integration of Circadian Exploration suite. Here, we demonstrate the Pipeline for Amplitude Integration of Circadian Exploration suite's increased utility to detect circadian trends through the joint modeling of the Mus musculus macrophage transcriptome and proteome. Our enhanced detection confirmed extensive circadian posttranscriptional regulation in macrophages but highlighted that some of the reported discrepancy between mRNA and protein oscillations was due to noise in data. We further applied the Pipeline for Amplitude Integration of Circadian Exploration suite to investigate the circadian timing of noncoding RNAs, documenting extensive circadian timing of long noncoding RNAs and small nuclear RNAs, which control the recognition of mRNA in the spliceosome complex. By tracking oscillating spliceosome complex proteins using the PAICE suite, we noted that the clock broadly regulates the spliceosome, particularly the major spliceosome complex. As most of the above-noted rhythms had damped amplitude changes in their oscillations, this work highlights the importance of the PAICE suite in the thorough enumeration of oscillations in omics-scale datasets.