Factors affecting early antibiotic delivery in open tibial shaft fractures.

INTRODUCTION: The incidence of infection in open tibial shaft injuries varies with the severity of the injury with rates ranging from roughly 2% for Gustilo-Anderson type I to nearly 43% for type IIIB fractures. As with all fractures, timely antibiotics administration in the emergency department (ED) is an essential component of fracture management and infection prevention. This study identifies factors associated with the expedient administration of antibiotics for open tibial shaft fractures. METHODS: This retrospective study identified patients treated for open tibial shaft fractures at an academic level 1 trauma center between 2015 and 2021. Open fractures were identified by reviewing patient charts. We used chart reviews to gather demographics, fracture characteristics, postoperative outcomes, trauma activation, and time to antibiotic order, delivery, and operating room. Univariate analysis was used to compare patients who received antibiotics within 1 h of ED presentation to those who did not. Multivariate analysis was performed to investigate factors associated with faster delivery of antibiotics. RESULTS: Among 70 ED patients with open tibial shaft fractures, 39 (56%) received early administration of antibiotics. Arrival at the ED via emergency medical service (EMS) as opposed to walking in (98% vs. 74%, p = 0.01) and trauma activation (90% vs. 52%, p < 0.001) were significantly more common in the early administration group than the late group. The early group had shorter intervals between antibiotic order and delivery (0.02 h vs. 0.35 h, p = 0.007). Multivariate analysis suggested that trauma activation, EMS arrival, and arrival during non-overnight shifts were independent predictors of a shorter time to antibiotic administration (odds ratios 11.9, 30.7, and 5.4, p = 0.001, 0.016, and 0.013, respectively). DISCUSSION: Earlier antibiotic delivery is associated with non-overnight arrival at the ED, arrival via EMS, and a coordinated trauma activation. Our findings indicate that in cases where administering antibiotics is critical to achieving positive outcomes, it is advisable to initiate a coordinated trauma response. Furthermore, hospital personnel should be attentive to the need for rapid administration of antibiotics to patients with open fractures who arrive via walk-in or during late-night hours.

The Cost-Effectiveness of Smoking Cessation Programs for Prevention of Wound Complications Following Total Ankle Arthroplasty: A Break-Even Analysis.

Background: Tobacco use significantly increases the rate of wound complications in patients undergoing total ankle arthroplasty (TAA). Preoperative optimization through smoking cessation programs significantly minimizes the rate of infection and improves wound healing in arthroplasty procedures. Despite its utility, minimal research has examined the cost-effectiveness of preoperative smoking cessation programs to reduce the need for extracapsular irrigation and debridement (I&D) due to wound complications following TAA. Methods: The cost of an I&D procedure was obtained from our institution's purchasing records. Baseline wound complication rates among tobacco users who have undergone TAA and smoking cessation program cost were obtained from literature. A break-even economic analysis was performed to determine the absolute risk reduction (ARR) to economically justify the implementation of preoperative smoking cessation programs. Different smoking cessation program and I&D costs were tested to account for variations in each factor. ARR was then used to calculate the number needed to treat (NNT) to prevent a single I&D while remaining cost-effective. Results: Smoking cessation programs were determined to be economically justified if it prevents 1 I&D surgery out of 8 TAAs among tobacco users (ARR = 12.66%) in the early postoperative period (<30 days). ARR was the same at the literature high (27.3%) and weighted literature average (13.3%) complication rates when using the cost of I&D surgery at our institution ($1757.13) and the literature value for a smoking cessation program ($222.45). Cost-effectiveness was maintained with higher I&D surgery costs and lower costs of smoking cessation treatment. Conclusion: Our model's input data suggest that the routine use of smoking cessation programs among tobacco users undergoing TAA is cost-effective for risk reduction of I&D surgery in the early postoperative period. This intervention was also found to be economically warranted with higher I&D costs and lower smoking cessation program costs than those found in the literature and at our institution.Level of Evidence: Level III, economic and decision analysis.

The weight of complications: high and low BMI have disparate modes of failure in total hip arthroplasty.

BACKGROUND: Body mass index (BMI) has been shown to influence risk for revision total hip arthroplasty (rTHA), but few studies have specifically examined which causes of rTHA are most likely in different BMI classes. We hypothesized that patients in different BMI classes would undergo rTHA for disparate reasons. METHODS: Ninety-eight thousand six hundred seventy patients undergoing rTHA over 2006-2020 were identified in the National Inpatient Sample. Patients were classified as underweight, normal-weight, overweight/obese, or morbidly obese. Multivariable logistic regression was used to analyze the impact of BMI on rTHA for periprosthetic joint infection (PJI), dislocation, periprosthetic fracture (PPF), aseptic loosening, or mechanical complications. Analyses were adjusted for age, sex, race/ethnicity, socioeconomic status, insurance, geographic region, and comorbidities. RESULTS: Compared to normal-weight patients, underweight patients were 131% more likely to have a revision due to dislocation and 63% more likely due to PPF. Overweight/obese patients were 19% less likely to have a revision due to dislocation and 10% more likely due to PJI. Cause for revision in morbidly obese patients was 4s1% less likely to be due to dislocation, 8% less likely due to mechanical complications, and 90% more likely due to PJI. CONCLUSIONS: Overweight/obese and morbidly obese patients were more likely to undergo rTHA for PJI and less likely for mechanical reasons compared to normal weight patients. Underweight patients were more likely to undergo rTHA for dislocation or PPF. Understanding the differences in cause for rTHA among the BMI classes can aid in patient-specific optimization and management to reduce postoperative complications. LEVEL OF EVIDENCE: III.

Research Productivity and Impact in Foot and Ankle Surgery: Insights From Relative Citation Ratio Analysis of Recent Fellowship Graduates.

INTRODUCTION: The relative citation ratio (RCR), a novel bibliometric tool supported by the National Institute of Health, provides a standardized approach to evaluate research productivity and impact across different fields. This study aims to evaluate RCR of fellowship-trained foot and ankle orthopaedic surgeons to analyze the influence of various surgeon demographics. METHODS: Fellow names listed on the American Orthopaedic Foot and Ankle Society website were extracted from the year 2008 to 2009 to the year 2022 to 2023. Demographic information for each fellow was collected including sex, degree type, and academic title. The iCite database developed by the National Institute of Health was used to obtain total publications, mean RCR, weighted RCR, and change in RCR after fellowship graduation for each fellow. Univariate and multivariate analysis was conducted to predict these four parameters based on sex, degree type, academic position, and career longevity. RESULTS: Of the 820 fellows, 674 (82%) were male. Most fellows (n = 587, 71%) did not go on to hold academic positions. Multivariate analysis revealed that male sex (ß = 2.32, P < 0.001), holding an academic position (ß = 6.44, P < 0.001), holding a PhD (ß = 22.96, P < 0.001), and a shorter length time since graduation (ß = -0.50, P < 0.001) were independent predictors of number of total publications. Holding a DO degree was an independent predictor of decreased mean RCR (ß = 0.39, P = 0.039). Finally, multivariate analysis revealed that male sex (ß = 4.05, P = 0.003), a career in academics (ß = 4.61, P < 0.001), and a shorter time since graduation (ß = -0.45, P = 0.001) were associated with a larger weighted RCR. DISCUSSION: The findings highlight the importance of addressing gender disparities and promoting research opportunities across different programs. Moreover, academic institutions should provide adequate support and mentorship to early-career foot and ankle-trained orthopaedic surgeons to foster sustained research productivity.

Gender diversity at spine surgery academic conferences: a 15-year investigation.

BACKGROUND CONTEXT: Enhancing gender diversity at academic conferences is critical for advancing women's representation and career trajectories in spine surgery. PURPOSE: To discover trends in women's representation at major spine conferences over a 15-year period. STUDY DESIGN/SETTING: Conference records from the 2007-2021 annual meetings of the Congress of Neurological Surgeons, North American Spine Society, and Scoliosis Research Society (SRS). PATIENT SAMPLE: Authors of spine-related presentations. OUTCOME MEASURES: Authorship by gender. METHODS: Retrospective bibliometric analysis with univariate and multivariate modeling to identify trends and predictors of gender diversity. RESULTS: Among 8,948 presentations, 750 (8.4%) had female first authors and 618 (6.9%) had female senior authors. There was no change in rates of female first authorship (p=.41) or senior authorship (p=.88) over time. The strongest predictors of female first authorship were having a female senior author (OR 7.32, p<.001), and delivering presentations at SRS (OR 1.95, p=.001). Factors negatively associated with female first authorship included poster format (OR 0.82, p=.039) and conference location in the United States/Canada (OR 0.76, p=.045). Similar trends were encountered for senior authorship. Productivity per senior author was similar between genders (p=.160); whereas a gender gap in productivity per first author during 2007 to 2011 (p=.020) equalized by 2017 to 2021 (p=.300). Among the 10 most productive authors of each gender, male authors delivered more presentations, but all authors shared similar format, content, and location. CONCLUSIONS: Women's representation in spine-related presentations did not increase at three major conferences over a 15-year period. Our findings regarding the positive effects of female mentorship, and international or virtual venues merit further investigation to address the gender gap. The upstream pipeline of recruiting women into academic spine surgery also needs to be addressed.

Predicting Mortality Following Odontoid Fracture Fixation in Elderly Patients: CAADS-16 Score.

STUDY DESIGN: Retrospective Review of a National Database. INTRODUCTION: By utilizing a national database, this study aims to quantify the predictors of 30-day mortality after odontoid fixation and guide appropriate management for patients in whom the choice between operative and non-operative management is unclear. METHODS: The American College of Surgeons National Surgical Quality Improvement Database was queried using Current Procedural Terminology (CPT) codes and International Classification of Disease (ICD) codes to identify patients 60 or older who underwent surgical fixation of an odontoid fracture from 2005 to 2020. Risk factors for mortality significant in univariate and subsequent multivariate analysis were used to develop a scoring system to predict post-operative mortality. RESULTS: 608 patients were identified. Patients were split into a non-mortality 30 days post-op group, and into a mortality 30 days post-op group. The following risk factors were included in the scoring system: functional dependency, disseminated cancer, albumin less than 3.5, WBC count greater than 16 k, anterior surgical approach, and pre-op SIRS. Using a cutoff value of 2, the CAAD-16 score had a sensitivity and specificity of 82% and 81%, respectively. The ASA score, cutoff at 4, showed a sensitivity and specificity of 64% and 75% respectively. CONCLUSIONS: This sample of 294 patients represents one of the largest samples of odontoid fracture fixation patients available in the literature and comes from a nationally representative database. We structure relevant risk factors into the CAADS-16 score, which has the potential to be a clinically relevant tool to prevent short-term postoperative mortality.

Google Trends Analysis of Peripheral Nerve Disease and Surgery.

BACKGROUND: Despite advances in the surgical management of peripheral nerve pathologies over the past several decades, it is unknown how public awareness of these procedures has changed. We hypothesize that Google searches for peripheral nerve surgery have increased over time. METHODS: Google Trends was queried for search volumes of a list of 40 keywords related to the following topics in peripheral nerve surgery: spasticity, nerve injury, prosthetics, and nerve pain. Monthly relative search volume over the first 5 years of the study period (2010-2014) was compared with that of the last 5 years (2018-2022) of the study period. RESULTS: Search volumes for keywords "nerve injury," "nerve laceration," "peripheral nerve injury," "nerve repair," "nerve transfer", "neuroma," "neuroma pain," "nerve pain," "nerve pain surgery," and "neuroma pain surgery" all increased more than 10% points in relative search volume over the study period (P < 0.0001 for each keyword). In contrast, searches for "rhizotomy," "spasticity surgery," "targeted muscle reinnervation," "bionic arm," and "myoelectric prosthesis" either decreased or remained stable. Technical terms such as "selective neurectomy," "hyperselective neurectomy," "regenerative peripheral nerve interface," and "regenerative peripheral nerve interface surgery" did not have adequate search volume to be reported by Google Trends. CONCLUSIONS: The increase in Google searches related to nerve injury and pain between 2010 and 2022 may reflect increasing public recognition of these clinical entities and surgical techniques addressing them. Technical terms relating to nerve pain are infrequently searched, surgeons should use plain English terms for online discovery. Interest in spasticity and myoelectric prosthetics remains stable, indicating an opportunity for better public outreach.

The cost effectiveness of tranexamic acid for preventing periprosthetic joint infection following total shoulder arthroplasty: a break-even analysis.

BACKGROUND: The use of tranexamic acid (TXA) has become widespread in orthopedics to promote hemostasis and has been successfully used to reduce blood loss and infection risk in joint arthroplasty. However, the cost effectiveness of routine TXA use for the prevention of periprosthetic infections in total shoulder arthroplasty remains unknown. METHODS: The acquisition cost of TXA ($5.22) for our institution, along with values from the literature for the average cost of infection-related care ($55,243) and the baseline infection rates for patients without TXA use (0.70%),were used to perform a break-even analysis. The absolute risk reduction (ARR) of infection necessary to justify the prophylactic use of TXA in shoulder arthroplasty was calculated from the nontreated and break-even infection rates. RESULTS: TXA is considered cost-effective if it prevents one infection out of 10,583 total shoulder arthroplasty's (ARR = 0.009%). It is economically justifiable with an ARR range of 0.001% at a cost of $0.50/g to 0.181% at $100/g. At varying costs of infection-related care ($10,000-$100,000) and varying baseline infection rates (0.50%-8.00%) and routine use of TXA remained cost-effective. CONCLUSION: The use of TXA is an economically viable practice for infection prevention following shoulder arthroplasty if it reduces the infection rate by 0.009%. Future, prospective studies should be conducted to observe whether TXA reduces the infection rate by more than 0.009%, showing cost effectiveness.

Return to Play after Posterior Cruciate Ligament Injuries.

PURPOSE OF REVIEW: Posterior cruciate ligament injuries can be treated conservatively with a structured rehabilitation program or with surgical reconstruction. Treatment algorithms are based on a variety of factors including the patient's presentation, physical exam, and desired level of activity. The goal is to return the patient to their athletic pursuits with a stable and pain-free knee. Return to play and activities should be individualized based on the patient's injury and progression through rehabilitation. This article provides a review of the current treatments for posterior cruciate ligament injuries and the respective rehabilitation protocols, outcomes after each treatment option, and specific return to play criteria. RECENT FINDINGS: Current research shows excellent outcomes and return to play with conservative treatment of isolated posterior cruciate ligament injuries. Return to play algorithms stress the importance of quadriceps strengthening throughout the recovery process and emphasize inclusion of plyometrics and sport-specific training. Rehabilitation plays a critical role in the outcome after posterior cruciate ligament injury and the ability to return to athletics. The primary focus of post-injury or post-operative rehabilitation is to restore function, as it relates to range of motion, strength, and proprioception, while mitigating swelling and pain. The patients' desired sport and level of play dictate return to play timelines. The literature supports the use of non-operative management of isolated PCL injuries in athletes and non-athletes with excellent functional and patient-reported outcomes.

Motorcycle-Associated Ocular Injuries: A Narrative Review.

Purpose: Motorcycle-related injuries involving the eye and orbit are not well characterized, with a paucity of prospective studies focusing specifically on motorcycle-associated eye injuries nor literature reviews having been conducted on the subject. To better understand the injury types and descriptive characteristics of patients experiencing motorcycle-associated eye injuries, we sought to conduct a narrative review. Methods: The research team utilized the following databases: PubMed, EMBASE, and Web of Science to query for English articles from peer-reviewed journals that provided some patient data regarding eye injury due to motorcycle or moped accidents or usage. Results: A total of 65 studies were included in our qualitative synthesis. Of these studies, 40 (61.5%) were case reports, 20 retrospective case series (30.8%), and five (7.69%) were observational prospective studies. Among the 25 retrospective and prospective studies, 12 (48.0%) of these studies primarily focused on motorcycle-associated injuries. These 65 studies described a wide variety of motorcycle-associated eye injuries, including but not limited to orbital fractures and associated sequelae, foreign bodies, vitreoretinal trauma, neuro-ophthalmic trauma, corneal injuries, open globe injuries, lacerations, and globe avulsions. Conclusion: The current state of the literature indicates that knowledge regarding the ocular manifestations of motorcycle accidents is limited to mostly case reports and few retrospective cohort studies focused specifically on motorcycle-associated eye injuries. However, it is evident that the types of motorcycle-associated eye injuries are legion and predominantly seen in adult males, potentially leading to severe injuries and loss of vision and blindness.

A 20-year nationwide analysis of golf-associated eye injuries in the United States.

PURPOSE: Existing knowledge regarding golf-associated eye injuries (GEIs) is sparse. The purpose of this study was to characterize the types of GEIs, examine the mechanisms of injury, describe the characteristics of GEI victims, and determine the incidence of GEIs during the 2002-2021 period using the National Electronic Injury Surveillance System (NEISS) database. METHODS: Deidentified patient records were analyzed. Each GEI was assigned into a specific category of diagnosis, and the mechanism of injury was determined. National estimates were collected for each year, and simple linear regression modeling was used to determine trends over time. Furthermore, patient variables for sex, race, and age were analyzed. RESULTS: The NEISS query provided a total of 379 GEIs for analysis. GEIs were most common in adult males, with a decreasing, although not statistically significant, trend during this period (ß = -17.88, p = 0.110). Children were more likely to have a GEI caused by a golf club while adults were more likely to have one caused by the surrounding environment. Across all age groups, contusions and corneal abrasions were the most common GEIs, constituting 50.4% (190/377) of all eye injuries, followed by foreign body injuries (9%, 34/377) and then irritation/inflammation of the eye (8%, 30/377). The most common mechanism of injury among all players involved adverse interactions with the environment (37.7%, 142/377). CONCLUSION: Contradictory to existing literature, we show that minor GEIs are more common than severe ones. Rather than golf clubs or balls, environmental elements are the leading cause of GEIs.

Quantitative Interactomics of Lck-TurboID in Living Human T Cells Unveils T Cell Receptor Stimulation-Induced Proximal Lck Interactors.

While Lck has been widely recognized to play a pivotal role in the initiation of the T cell receptor (TCR) signaling pathway, an understanding of the precise regulation of Lck in T cells upon TCR activation remains elusive. Investigation of protein-protein interaction (PPI) using proximity labeling techniques such as TurboID has the potential to provide valuable molecular insights into Lck regulatory networks. By expressing Lck-TurboID in Jurkat T cells, we have uncovered a dynamic, short-range Lck protein interaction network upon 30 min of TCR stimulation. In this novel application of TurboID, we detected 27 early signaling-induced Lck-proximal interactors in living T cells, including known and novel Lck interactors, validating the discovery power of this tool. Our results revealed previously unappreciated Lck PPI which may be associated with cytoskeletal rearrangement, ubiquitination of TCR signaling proteins, activation of the mitogen-activated protein kinase cascade, coalescence of the LAT signalosome, and formation of the immunological synapse. In this study, we demonstrated for the first time in immune cells and for the kinase Lck that TurboID can be utilized to unveil PPI dynamics in living cells at a time scale consistent with early TCR signaling. Data are available via ProteomeXchange with identifier PXD020759.

In-depth Analysis of Adult Reconstruction Fellowship Websites.

This investigation assessed the availability and comprehensiveness of adult reconstruction fellowship websites. A list of adult reconstruction fellowship programs was compiled using 4 online directories: American Association of Hip and Knee Surgeons, San Francisco Match, Fellowship and Residency Electronic Interactive Database Access, and American Academy of Orthopaedic Surgeons. These directories and Google (Alphabet Inc, Menlo Park, California) searches were used to assess for the presence and functionality of websites for each program. Each website was reviewed for the presence of 21 variables related to education and recruitment. The relationship between several program characteristics and presence of a website or website comprehensiveness was evaluated. In total, 81 programs were identified, of which 80.2% (65 of 81) had a functional website and 19.8% (16 of 81) did not. The mean±SD number of variables present on a website was 11.3±3.8 of 21 total variables, equating to mean comprehensiveness of 54.0%. Fellowships affiliated with an orthopedic residency were more likely to have a website than those that were not (91.8% vs 62.5%, P=.001). Fellowships that were accredited by the Accreditation Council for Graduate Medical Education were more likely to have a website than those that were not (100.0% vs 73.8%, P=.009). Website comprehensiveness was not associated with any program characteristics assessed. This study highlights deficits in online resources available for adult reconstruction fellowship program information and the gap that exists between the current means of information sharing. Efforts to encourage an online presence and optimize a program's online content may be of benefit to prospective applicants and the program itself. [Orthopedics. 2020;43(5):e447-e453.].