Hospital transfer and delayed reduction of traumatic hip dislocations.

INTRODUCTION: Native hip dislocations are high energy injuries that cause substantial patient morbidity. Expedient reduction has been demonstrated to improve patient outcomes. The objective of our study was to compare complication rates in patients with native hip dislocations who presented directly to a level-one trauma center with those transferred from an outside hospital (OSH). Our hypothesis was that those transferred from an OSH would experience a delay in reduction and subsequently would experience higher rates of avascular necrosis (AVN), post-traumatic arthritis (PTA), and need for secondary surgery. MATERIAL AND METHODS: We conducted a retrospective chart review of all native hip dislocations from our level-one trauma center between January 2007 and December 2020. The initial query resulted 628 patients which was refined to 90 patients after excluding patients for incorrect diagnosis code or less than 6 months of follow-up. Our primary outcome was the development of AVN, PTA, and need for secondary surgery. Time from injury to reduction was recorded for all patients included. RESULTS: For every one hour of delay in time to reduction, there was a 3.4% increase in the risk of developing AVN (p = 0.004) and a 4.3% increase in risk for developing PTA (p = 0.01). The risk of requiring a secondary surgery increased 4.6% for each hour of delay in reduction (p = 0.03). The average time to reduction of transferred patients was higher compared to those who presented directly to our center (13.8 h vs 5.7 h); however, transfer status was not found to be an independent risk factor for the measured outcomes. CONCLUSIONS: Transfer status is not an independent risk factor for the development of AVN, PTA, or the need for a secondary surgery. However, transferred patients did experience an average delay of 8 h in time to reduction compared to those who presented directly to a trauma center. Of the 27 patients with a reduction delay greater than 12 h, 26 (96%) were transferred.

Discriminatory questions asked during residency programme interviews: perspective from both interviewers and applicants.

BACKGROUND: The National Resident Matching Program (NRMP) policy requires interview officials to refrain from asking illegal or coercive questions that may introduce discrimination; however, compliance is insufficient. METHOD: An Institutional Review Board-approved 12 question survey was distributed to 130 allopathic medical schools with 551 responses from 18 187 students applying in the 2015-2016 residency match. In addition, a 16-question survey was distributed through residency coordinators to residency programme interviewers with 481 responses from 21 of 22 residency specialities. RESULTS: Discriminatory topics were frequently discussed across all specialities. Surgical interviews were significantly more likely to discuss age (relative risk (RR) 2.0, p<0.01) and gender (RR 2.7, p<0.01) during formal interviews. More-competitive specialities more frequently discussed age (RR 1.9, p<0.01) and gender (RR 2.0, p<0.01) during the formal interview, and gender (RR 1.4, p<0.05) during informal interview events. 47.8% of interviewers discussed potentially coercive topics during the interview, 57.5% considered these topics when evaluating candidates and 72.6% had misunderstandings. Interviewers given both oral and written instruction showed the greatest effect change towards discussing coercive topics (p<0.01) and correctly identifying non-discriminatory and discriminatory topics (p<0.01). While age and gender both constitute discriminatory topics, each of these topics is included in the majority of written The Electronic Residency Application System applications (85.5% and 89.8%, respectively). CONCLUSIONS: In modern recruitment where differential attainment is of interest, the presence of such explicit discrimination is worrisome. Formal interview training might reduce discrimination, but more active overnight is needed and a zero-tolerance approach to overt discrimination should be the ambition.

Ankle fusion following failed initial treatment of complex ankle fractures in neuropathic diabetics.

BACKGROUND: Unstable ankle fractures in diabetics with peripheral neuropathy have an increased risk of postoperative complications, often leading to amputation. Primary ankle arthrodesis has been suggested as an alternative when acceptable reduction and mechanical stabilization cannot be obtained. METHODS: Over a fourteen year period, thirteen diabetic patients with peripheral neuropathy underwent an attempt at primary ankle arthrodesis following the early post-fracture development of acute neuropathic (Charcot) deformity of the ankle after sustaining a low energy unstable ankle fracture. Eight patients with open wounds and osteomyelitis underwent single stage debridement of the osteomyelitis and primary ankle fusion with an ankle fusion construct circular external fixator. Five patients without evidence of infection underwent primary arthrodesis with a retrograde locked intramedullary nail used for fixation. A successful clinical outcome was achieved with either successful radiographic arthrodesis or stable pseudarthrosis, when community ambulation was achieved with commercially-available therapeutic footwear and a short ankle orthosis. RESULTS: Eight of the thirteen patients achieved a successful clinical outcome at a mean follow-up of 48 (range 12-136) months following the initial surgery. Three achieved clinical stability following a second surgery and one following a third. One patient with radiographic nonunion expired due to unrelated causes. One patient underwent transtibial amputation due to persistent infection. Of the five patients with failure of radiographic union, three successfully ambulated in the community with a short ankle orthosis. Postoperative complications included wound and pin-site infection, infected nonunion, chronic wounds, and tibial stress fracture. CONCLUSION: In spite of the high risk for complications and initial failure, primary ankle fusion is a reasonable option for diabetic neuropathic patients who develop acute neuropathic arthropathy following ankle fracture. LEVEL OF EVIDENCE: Level IV retrospective case series.

Increased Heat Shock Protein Expression Decreases Inflammation in Skeletal Muscle During and after Frostbite Injury.

BACKGROUND: Frostbite injury results in serious skeletal muscle damage. The inflammatory response due to frostbite causes local muscle degeneration. Previous studies have shown that heat shock proteins (hsps) can protect against inflammation. In addition, our previous studies showed that increased expression of hsp70 is able to protect skeletal muscle against cryolesion. METHODS: Therefore, our aim was to determine if the induction of the heat shock proteins are able to minimize inflammation and protect skeletal muscle against frostbite injury. RESULTS: In the present study, we used the hsp90 inhibitor, 17-dimethylaminoethylamino- 17-demethoxygeldanamycin (17-DMAG), which was administered within 30 minutes following frostbite injury. Rat hind-limb muscles injected with 17-DMAG following frostbite injury exhibited less inflammatory cell infiltration as compared to control rat hind-limb muscles. In agreement with this observation, it has been observed that increased hsp expression resulted in decreased inflammatory cytokine expression. Additionally, we found that the administration of 17-DMAG after frostbite injury can preserve muscle tissue structure as well as function. CONCLUSION: It has been concluded that compounds such as 17-DMAG that induce the heat shock proteins are able to preserve skeletal muscle function and structure if injected within 30 minutes after frostbite injury. Our studies provide the basis for the development of a potential therapeutic strategy to treat the injury caused by frostbite.

The influence of biplanar reduction and surgeon experience on proximal humerus fractures treated with ORIF.

BACKGROUND: Treatment for proximal humerus fractures remains controversial. Studies of open reduction and internal fixation (ORIF) rarely account for reduction quality, while surgeon experience and sagittal plane reduction remain unstudied. In a retrospective case series analysis of AO/OTA C-type proximal humerus fractures treated with ORIF using a locking plate, we hypothesized that reduction quality would be associated with outcome, and reductions would improve with experience. METHODS: We retrospectively identified 41 3- and 4-part proximal humerus fractures treated with ORIF by a single orthopaedic traumatologist. Two blinded traumatologists assessed injury and post-operative radiographs for medial calcar disruption and five measures of deformity. Major complications and functional outcome were assessed. RESULTS: Outcome by ASES score was similar to previous reports (mean 73.6, std dev 22.5). Eleven of 35 patients (31.4%) with greater than six months follow-up experienced a complication. Post-reduction sagittal HSa<25° (RR = =9.44, p = =0.024) and medial calcar disruption (RR = =3.82, p = =0.009) were associated with complications. Post-reduction coronal and sagittal HSa improved with experience (p < 0.001 and p = =0.032, respectively) as did the likelihood of overall anatomic reduction (p = =0.006). ROC analysis found a threshold for superior reduction quality after 23 cases (AUC = =0.873, p < 0.001). CONCLUSION: Sagittal reduction quality and medial calcar disruption were associated with complications. Additionally, reduction quality improved with experience. Future studies of proximal humerus ORIF should include multiplanar assessments of reduction while accounting for surgeon experience.

Surgical Technique: Anterolateral Approach to the Humerus.

INTRODUCTION: Although most humeral shaft fractures can be treated nonoperatively, many patients do benefit significantly from surgical treatment. The anterolateral approach to the humerus provides excellent exposure to the humeral shaft, especially to more proximal aspects. In addition, the approach can be extended both proximally and distally, providing the surgeon a dynamic exposure to the humerus for the treatment of fractures and other pathologies. METHODS: This video highlights a clinical case where a mid-shaft humerus fracture was diagnosed and treated with open reduction internal fixation using an 8-hole 4.5-mm limited contact dynamic compression plate through an anterolateral approach. RESULTS: We present indications, anatomic considerations, and surgical techniques used to surgically treat a transverse, mid-shaft humerus fracture through an anterolateral approach. In addition, we demonstrate the use of a push-pull screw to aid in achieving appropriate compression across a fracture site. Using this technique, an anatomic reduction and satisfactory clinical outcome were achieved. CONCLUSIONS: The anterolateral approach to the humerus offers excellent exposure to some humeral shaft fractures, particularly those that lie more proximally. However, its use must be weighed carefully against several other approach options, and the surgeon must account for the specific fracture pattern, as well as their own comfort and familiarity with the approach.

Surgical Technique: Achieving Anatomic Alignment With Temporizing, Ankle-Spanning External Fixation.

INTRODUCTION: Severe injuries to the ankle frequently result in soft tissue trauma too severe to proceed with immediate definitive fixation. Additionally, patients with multiple or vascular injuries may need a temporizing measure before undergoing definitive treatment. Temporizing, ankle-spanning external fixation offers a management strategy that allows for soft tissue rest and prioritized treatment of patients with polytrauma. METHODS: The video demonstrates 2 clinical cases managed with temporizing, ankle-spanning external fixation: a pilon fracture and a bimalleolar ankle fracture-dislocation. RESULTS: The indications, advantages, and a systematic operative approach to applying ankle-spanning external fixation are presented. Specific attention is paid to restoring an anatomic alignment of the ankle. CONCLUSIONS: Temporizing, ankle-spanning external fixation is an important modality in the management of fractures about the ankle, especially in patients with dislocation and/or severe soft tissue injury. A systematic approach that initially addresses length, followed by sagittal and coronal plane correction, can be used to restore anatomic alignment of the ankle.

Surgical Technique: Achieving Reduction With Temporizing, Knee-Spanning External Fixation.

INTRODUCTION: Peri- and intra-articular fractures about the knee are frequently managed with joint-spanning external fixation before definitive treatment. With a systematic approach, a near-anatomic reduction with respect to length, alignment, and rotation can be obtained. METHODS: This video highlights 2 clinical cases: a bicondylar tibial plateau fracture-dislocation and a distal femur fracture, both of which were treated with temporizing, knee-spanning external fixation. RESULTS: The indications, principles, and biomechanics of knee-spanning external fixation are presented. In addition, we demonstrate a systematic approach to applying knee-spanning external fixation. CONCLUSIONS: Temporizing, joint-spanning external fixation is a critical treatment modality in the orthopaedic armamentarium for managing fractures about the knee. With a systematic approach, it is possible to obtain a near-anatomic reduction with respect to length, alignment, and rotation.

Total hip arthroplasty and femoral nail lengthening for hip dysplasia and limb-length discrepancy.

The application of distraction osteogenesis through the use of magnet-operated, remote-controlled intramedullary lengthening continues to provide new opportunities for accurate limb equalization. While limb-length discrepancy and deformity can be addressed by total hip arthroplasty alone, the magnitude of correction is limited by the soft-tissue envelope and complications such as sciatic nerve palsy. This 3-patient case series presents the combination of staged ipsilateral total hip arthroplasty and retrograde intramedullary femoral nail lengthening for the correction of both deformity and limb-length discrepancy. Our results report leg-length equalization, independent ambulation without assistive devices, and excellent bone and functional outcomes without complications, demonstrating that this combined technique can be used to achieve targeted lengthening and deformity correction.

The Economic Burden of Residency Interviews on Applicants.

Background: The residency match is increasingly competitive. The interview is an essential component, yet little has been documented about the costs applicants incur during the interview process and it is unclear how they manage these expenses. Objective: The purpose of this study was to define the economic burden of residency interviews for United States (U.S.) allopathic students participating in the 2016 Main Residency Match. We hypothesized that the financial burden of residency interviews varies based on specialty and plays a role in the applicant's ability to participate in all desired interviews. Methods: A 26 question electronic survey was developed following pilot study of applicants to a single residency program. Following validation, the survey was distributed to administrative officials at all U.S. allopathic medical schools for circulation to senior students. Results were pooled for statistical analysis. Results: We received responses from 759 U.S. allopathic seniors. A single interview most commonly costs $250 - $499. Most applicants incurred substantial interview related costs. Sixtyfour percent of respondents spent at least $2,500, while 13% spent $7,500 or more. Specialty competitiveness was predictive of higher interview costs. Seventy-one percent of respondents borrowed money to fund interview costs, and 41% declined interviews for financial reasons. Conclusions: Senior medical students incur substantial costs to participate in residency interviews, often adding to already burdensome educational debt. We encourage residency programs, especially those in competitive specialty fields, to pursue cost reduction strategies. Additionally, medical schools should provide financial counseling to allow students to anticipate interview costs.

Targeted three-dimensional liquid chromatography: a versatile tool for quantitative trace analysis in complex matrices.

Targeted multidimensional liquid chromatography (MDLC), commonly referred to as 'coupled-column' or 'heartcutting', has been used extensively since the 1970s for analysis of low concentration constituents in complex biological and environmental samples. A primary benefit of adding additional dimensions of separation to conventional HPLC separations is that the additional resolving power provided by the added dimensions can greatly simplify method development for complex samples. Despite the long history of targeted MDLC, nearly all published reports involve two-dimensional methods, and very few have explored the benefits of adding a third dimension of separation. In this work we capitalize on recent advances in reversed-phase HPLC to construct a three-dimensional HPLC system for targeted analysis built on three very different reversed-phase columns. Using statistical peak overlap theory and one of the most recent models of reversed-phase selectivity we use simulations to show the potential benefit of adding a third dimension to a MDLC system. We then demonstrate this advantage experimentally by developing targeted methods for the analysis of a variety of broadly relevant molecules in different sample matrices including urban wastewater treatment effluent, human urine, and river water. We find in each case that excellent separations of the target compounds from the sample matrix are obtained using one set of very similar separation conditions for all of the target compound/sample matrix combinations, thereby significantly reducing the normally tedious method development process. A rigorous quantitative comparison of this approach to conventional 1DLC-MS/MS also shows that targeted 3DLC with UV detection is quantitatively accurate for the target compounds studied, with method detection limits in the low parts-per-trillion range of concentrations. We believe this work represents a first step toward the development of a targeted 3D analysis system that will be more effective than previous 2D separations as a tool for the rapid development of robust methods for quantitation of low concentration constituents in complex mixtures.