Does Automated Impaction Improve Femoral Component Sizing and Alignment in Total Hip Arthroplasty?

BACKGROUND: While automated impaction can provide a more standardized process for femoral canal preparation, little is known regarding its effect on femoral component sizing and position. The purpose of our study was to directly compare femoral component canal fill ratio (CFR) and coronal alignment between primary total hip arthroplasty (THA) procedures performed with automated impaction versus manual mallet impaction. METHODS: A retrospective analysis was performed on 184 patients who underwent primary THA by a single arthroplasty surgeon between 2017 and 2021 with a modern cementless femoral component using either the direct anterior or posterolateral approach. The final cohort was divided into 2 groups based on impaction technique during broaching: automated (N = 122) or manual (N = 62). A propensity score match was used to match for age, body mass index, sex, high versus standard offset stem, and preoperative femoral bone quality. Radiographic review was performed to measure intramedullary prosthetic CFR and coronal alignment. RESULTS: The automated cohort trended toward the use of a larger stem (5.67 versus 4.82, P = .006) and had a larger CFR at all 4 levels within the proximal femur (P = .004). The automated cohort had a more valgus and reliable coronal alignment (-0.57 (SD 1.50) versus -0.03 (SD 2.17) degrees, P = .03) and significantly shorter operative time (mean 78 versus 90 minutes, P < .001). There were no intraoperative or postoperative periprosthetic fractures in either cohort. CONCLUSION: Automated impaction in primary THA is a safe technique for femoral preparation, which resulted in improved stem coronal alignment, optimized canal fill within the proximal femur, and reduced operative times.

Posterior Interosseous Neuropathy Related to a Loose Distal Biceps Cortical Button: A Case Series.

Posterior interosseous nerve (PIN) injury is an uncommon yet debilitating complication following distal bicep tendon repair. There are case reports of acute intraoperative PIN injury related to retractor placement, drill trajectory, and nerve incarceration. We report three cases of delayed PIN neuropathy in the setting of a loose cortical button. All patients had resolution of their pain with removal of the cortical button and decompression of the radial tunnel. The purpose of this case series is to: 1) highlight the possibility of a loose cortical bicep button as the cause of proximal forearm pain and PIN neuropathy in the early or late postoperative timeframe; and 2) emphasize the importance of proper surgical technique and use of intraoperative fluoroscopy to assure the cortical button is well-fixed and flush with the radial shaft. .

Evaluating inter- and intraobserver reliability in radiographic determination of wrist alignment following scaphoid excision and four-corner arthrodesis.

Background: Four-corner arthrodesis is commonly performed for advanced collapse patterns of wrist arthritis. Reduction of the capitolunate (CL) angle during four-corner fusion is crucial to allow for the greatest radiocarpal joint arc of motion. Previous studies demonstrate variable inter- and intraobserver reliability of measuring the CL angle. However, in a four-corner fusion, hardware implementation and scaphoid excision can complicate carpal alignment measurements. The purpose of this study is to investigate inter- and intraobserver reliability of measuring carpal alignment parameters following scaphoid excision and four-corner arthrodesis. Methods: Three fellowship-trained orthopaedic hand surgeons evaluated 30 posteroanterior and lateral radiographs of wrists after scaphoid excision and four-corner fusion. Radiographic evaluation included analysis of the radiolunate angle (RL), CL angle, lunate posture, carpal height, carpal height ratio, hardware impingement, and arthrodesis technique. Intraclass correlation coefficients (ICCs) and kappa values were used to evaluate reliability of radiographic measurements. Results: RL and CL angles demonstrated very good inter- (ICCs: 0.657 and 0.693, respectively) and intraobserver agreement (ICCs: 0.576 to 0.924 and 0.596 to 0.811, respectively). Hardware impingement metrics by dorsal prominence and radiocarpal prominence had excellent interobserver reliability of 0.821 and 0.803, respectively. ICC values for arthrodesis technique were equal to 1.00. The inter- and intraobserver ICC values for the number of screws/staples used were in excellent agreement ranging from 0.910 to 1.000. Conclusions: Our study demonstrated favorable intra- and interobserver reliability at assessing carpal alignment following scaphoid excision and four-corner arthrodesis and these metrics potentially could be used in future research to evaluate long-term surgical outcomes. Level of evidence: Level III, retrospective cohort study.

Analysis of Costs Associated With Increased Length of Stay After Total Joint Arthroplasty at a Single Private Practice.

INTRODUCTION: As the demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA) increases, so does the financial burden of these services. Despite efforts to optimize spending and bundled care payments, THA and TKA costs still need to be assessed. Our study explores the relationship between perioperative costs and length of stay (LOS) for THA and TKA. METHODS: A total of 614 patients undergoing THA or TKA at a single private practice with LOS from zero to 3 days were identified. All patients were insured by private or Medicare Advantage insurance from a single provider. Primary outcomes included total costs and their relationship with LOS, classified into surgeon reimbursement, facility costs, and anesthesia costs. Secondary outcomes included readmission rates and discharge disposition. Analyses involved Student t-test, analysis of variance, and chi-square tests. RESULTS: Longer LOS was associated with increased total, facility, and anesthesia costs. Costs for THA patients were stable except for reduced surgeon reimbursement with longer LOS. Patients undergoing TKA experienced an increase in facility costs with longer LOS. Total facility and anesthesia costs increased with LOS for Medicare Advantage patients, but surgeon reimbursement remained stable. Privately insured patients experienced higher total and facility costs but stable surgeon reimbursement and anesthesia costs regardless of LOS. CONCLUSION: Our study shows an increase in total cost with longer LOS, especially pronounced in privately insured patients. A notable reduction was observed in the surgeon reimbursement for Medicare Advantage patients with extended LOS. These findings underscore the need for efficient surgical practices and postoperative care strategies to optimize hospital stays and control costs.

Cleaning and Durability of Upper Extremity Orthotics: A Patient's Perspective.

Introduction We aimed to evaluate orthotic hygiene, preference for immobilization material, and frequency of unplanned orthotic adjustments and replacements. Methods All patients with fiberglass casts, thermoplastic splints, or prefabricated braces who presented at a large private academic institution between January 2020 and July 2023 were provided an 11-item survey assessing the length of immobilization, frequency of orthotic changes, orthotic hygiene, preference of immobilization, and whether patients recall instructions regarding orthotic care. Results A total of 385 surveys were collected, consisting of 96 (24.9%) casts, 202 (52.5%) thermoplastic splints, and 87 (22.6%) prefabricated braces. Patients were most frequently immobilized for two to six weeks. Of those, 106 (27.5%) patients required an unplanned adjustment or replacement. Almost half (182 patients, 47.3%) attempted to clean their orthotics, which was significantly greater among thermoplastic splints. A total of 229 (59.5%) respondents reported either not receiving or were unsure if they received instruction on proper orthotic hygiene. Conclusion Orthotic care and hygiene instructions are often overlooked or not retained by patients. Nearly one-third of patients required an unplanned adjustment or replacement, which was most frequent with thermoplastic orthotics.

Physical and Psychological Impact of Scar Cosmesis After Cervical Spine Fusion Surgery.

INTRODUCTION: Patients' and surgeons' perceptions of cutaneous scarring can vary, causing unpleasant physical and psychological outcomes. This study aims to bridge the current scientific literature gap and understand the impact of patient-perceived scar cosmesis after anterior and posterior cervical spine surgery. METHODS: Retrospective review of patients ≥18 years old who underwent anterior or posterior cervical spine surgery from 2017 to 2022 at a large, urban academic group. To select patients with adequate time for surgical scar maturation, only patients who were greater than 6 months postsurgery were included. The Scar Questionaire Survey (SCAR-Q) survey, a surgical scar assessment tool, was administered to patients to assess patient perceptions of scar symptomatology, appearance, and psychosocial impact. Scores range from 0 to 100, with 100 as the best outcome. An additional 5-item Likert scale question was administered to assess overall surgical satisfaction. RESULTS: All 854 respondents who completed the survey were stratified into 2 groups "Unsatisfied vs. Satisfied." Patients who were "unsatisfied" with their surgery had the lowest outcome scores for SCAR-Q appearance, symptom, and psychosocial scores than those who were "Satisfied" (P < 0.001). Females had significantly "higher/more favorable" responses for SCAR-Q Appearance (77.5 vs. 82.8 P < 0.001) and Psychosocial (87.4 vs. 94.3 P < 0.001) scores compared to males. Regression analysis performed for each component score showed that increases in all 3 component scores were significant in patients in the satisfied group. CONCLUSIONS: Our study demonstrates that cervical spine surgery patients unsatisfied with their surgical outcome have lower scar-related scores, highlighting the impact of cosmetic closure and appearance.

Trigger Finger Release: Are Sutures Requiring Removal Necessary?

Purpose: There is no consensus regarding optimal closure for trigger finger release (TFR) surgery. The purpose of this study was to compare the number of postoperative visits and complications following TFR closure with nonabsorbable sutures versus those following TFR closure with absorbable sutures and skin glue. The hypothesis was that wound closure with absorbable sutures and glue will result in fewer postoperative visits, while having similar complication rates as that with nonabsorbable sutures. Methods: A retrospective review identified all patients undergoing open TFR over a 3-year period performed by two hand surgery fellowship-trained hand surgeons who adhered to an identical surgical protocol except for incisional closure. Patients were divided into two groups: a control group with nonabsorbable 4-0 monofilament sutures requiring removal ("suture" group) and a study group with buried absorbable 4-0 monofilament sutures not requiring removal as well as skin glue ("glue" group). The data collected included age, sex, number of postoperative visits, wound complications, infections, antibiotic use, prescribed hand therapy, hospital admission, and reoperation. Results: A total of 305 open TFR surgeries in 278 patients were included in the study, with 155 digits in the "suture" group and 150 in the "glue" group. Both groups were similar in age and sex. The "suture" group had significantly more total postoperative visits (185 vs 42, respectively, P < .001) and postoperative visits within the first 2 weeks (155 vs 10, respectively, P < .001) than the "glue" group. Additional postoperative visits beyond 2 weeks of surgery were similar between the two groups. Three (1.9%) patients in the "suture" group and two (1.3%) patients in the "glue" group developed a superficial surgical site infection within 30 days after surgery. Neither had deep infections requiring hospitalization or reoperation. Both groups required similar rates of postoperative hand therapy. Conclusions: Absorbable sutures afford fewer postoperative visits while having a similar complication rate as nonabsorbable sutures requiring removal. Type of study/level of evidence: Therapeutic IV.

Mechanical Complications of Hip and Knee Spacers Are Common.

Introduction Two-stage revision is frequently used for the treatment of periprosthetic joint infection (PJI). Because antibiotic-loaded cement spacers are constructed and implanted as temporary devices, mechanical complications are possible. The purpose of our study was to define the incidence of such mechanical complications, determine associated risk factors, and establish if such complications influence the subsequent success of PJI treatment. Methods We identified patients who received an antibiotic spacer for the treatment of PJI at a single center over a six-year timeframe. Medical records and all radiographs were collected and reviewed. Radiographic changes over time were recorded, and mechanical complications were noted. We used multivariate logistic regression analysis to assess risk factors for mechanical spacer complications and assess whether such complications influence the likelihood of subsequent reimplantation and ultimate component retention. Results A total of 236 patients were included in the study. There were 82 hip spacers (28% dynamic and 72% static) with a mechanical complication rate of 8.5% and 154 knee spacers (44% dynamic and 56% static) with a mechanical complication rate of 18.2%. Knee spacers were significantly more likely to have mechanical complications than hip spacers. Other risk factors for mechanical complications included bone loss and elevated body mass index (BMI). Bone loss and advanced age were found to be independent risk factors for failure to undergo second-stage reimplantation. Mechanical spacer failure was not an independent risk factor for the likelihood of subsequent reimplantation or ultimate component retention. Conclusions Mechanical complications of antibiotic spacers are common but do not appear to negatively impact the likelihood of subsequent reimplantation or component retention. In knee spacers and in patients with bone loss or elevated BMI, appropriate patient counseling and strategies to prevent such complications are recommended.

Early Diet Liberalization After Anterior Lumbar Interbody Fusion Improves Postoperative Recovery.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: The objective of this study was to assess the impact of diet liberalization on short-term outcomes in patients undergoing anterior interbody lumbar fusion (ALIF). METHODS: A retrospective review was performed for patients undergoing ALIF at our tertiary care center institution from 2010 to 2022. Electronic medical records were reviewed for demographics, surgical characteristics, and 90-day postoperative outcomes. RESULTS: We included 515 patients in this study with 102 patients receiving a full diet on the same day as their operation. All other patients had a delay of at least 1 day (average 1.6 days) until a full diet was provided. This group was found to have a higher rate of postoperative ileus (10.2% vs 2.9%) and urinary retention (16.0% vs 3.9%). The readmission rate and percent of patients presenting to the emergency department within 90 days postoperatively were similar. On multivariate regression analysis, same-day, full-diet patients had decreased odds of developing urinary retention (OR = .17) and a shorter length of hospital stay (Estimate: -.99). Immediate full diet had no impact on the development of ileus (OR: .33). CONCLUSIONS: An immediate postoperative full diet following an anterior approach to the lumbar spine was not found to be associated with an increased risk of postoperative ileus in patients deemed appropriate for early diet liberalization. Moreover, an early full diet was found to reduce length of hospitalization and risk of postoperative urinary retention. Reconsideration of postoperative diet protocols may help optimize patient outcomes and recovery.

Tolerance for chronic heat exposure is greater in female than male mice.

PURPOSE: Chronic heat exposure in mice has cellular and physiological effects that improve thermal tolerance [1], but also modifies innate immune responses with potential adverse consequences [2]. While male and female mice are known to respond differently to acute exposure to severe hyperthermia, sex-based differences in responses to chronic moderate heat exposure have not been reported. The major objective of this study was to compare the tolerance of male and female mice for chronic heat exposure. MATERIALS AND METHODS: We used a mouse model of 5-day moderate heat exposure (ambient temperature ∼37°C) to compare the physiological and cellular heat shock response in male and female mice. Core temperature, heart rate, and activity were monitored telemetrically and heat shock protein levels were measured in brain and lung by western blotting. RESULTS: Adult CD-1 female mice maintained a 1.2°C lower core temperature (38.31 ± 0.64 versus 39.51 ± 0.72°C; p = 0.002), experienced less weight loss (1.54 ± 0.45 versus 4.54 ± 1.97 g; p = 0.0007), and had improved survival (16/16 survived versus 13/21, p < 0.006) than male mice of the same age. After 5 days of moderate heat exposure Hsp72 levels in brain and lung increased 2.1-fold (p = 0.007) and 5-fold (p = 0.048) in male mice compared with 1.3- (p = 0.054) and 1.5-fold (p = 0.134) in female mice. CONCLUSIONS: This study reveals previously unknown and potentially important differences between male and female mice in physiological and cellular responses to chronic heat exposure, which had consequences for survival. Future studies may identify biomarkers of differential heat tolerance and treatments to improve heat tolerance in humans.

Integrating the role of antifungal bacteria into skin symbiotic communities of three Neotropical frog species.

Chytridiomycosis, caused by the pathogen Batrachochytrium dendrobatidis (Bd), has led to population declines and extinctions of frog species around the world. While it is known that symbiotic skin bacteria can play a protective role against pathogens, it is not known how these defensive bacteria are integrated into the bacterial community on amphibian skin. In this study, we used 16S rRNA gene amplicon sequencing, culturing and Bd inhibition bioassays to characterize the communities of skin bacteria on three Neotropical frog species that persist in a Bd-infected area in Panama and determined the abundance and integration of anti-Bd bacteria into the community. We found that the two treefrog species had a similar bacterial community structure, which differed from the more diverse community found on the terrestrial frog. Co-occurrence networks also revealed differences between frog species such that the treefrogs had a significantly higher number of culturable Bd-inhibitory OTUs with high centrality scores compared with the terrestrial frog. We found that culture-dependent OTUs captured between 21 and 39% of the total relative abundance revealed in culture-independent communities. Our results suggest different ecological strategies occurring within skin antifungal communities on host species that have not succumbed to Bd infections in the wild.

Hands-on Pulmonary Curriculum: Interactive Learning Sessions on Oxygen Delivery, Spirometry, Positive Airway Pressure Devices, Tracheostomy, and Thoracostomy Tubes.

Introduction: Pulmonary equipment has become ubiquitous in clinical care. Basic device troubleshooting and mechanical manipulation skills are crucial to the practicing physician yet are frequently neglected in standard pulmonary curricula. Methods: We developed a hands-on pulmonary curriculum for medical residents and students, focusing on oxygen delivery, spirometry, positive airway pressure devices, thoracostomy, and tracheostomy knowledge. The curriculum, consisting of five 1-hour sessions, offers hands-on experience with basic pulmonary equipment relevant to the ICU and/or pulmonary clinic. Each session is led by a pulmonologist or critical care facilitator and designed for a learning audience of 10-15 internal medicine trainees and medical students. More than 11 sessions have been conducted since curriculum implementation. Results: Voluntary, immediate, pre- and postsession surveys assessed objective subject knowledge, perceived subject understanding, and perceived effectiveness of this hands-on format versus a conventional lecture style. A total of 52 learners returned surveys. Aggregate responses demonstrated that these sessions were typically the first formal training learners had received in these subject areas. Subject knowledge and perceived level of subject understanding both improved, and respondents reported the hands-on style of teaching was more effective than conventional lecture format. Discussion: Focused on practical knowledge, this pulmonary hands-on curriculum addresses a knowledge gap for medical trainees, has been enthusiastically received by trainees, and provides a useful resource for faculty wishing to teach about these devices.

Polymorphisms in human heat shock factor-1 and analysis of potential biological consequences.

The stress-activated transcription factor, heat shock factor-1 (HSF1), regulates many genes including cytoprotective heat shock proteins (HSPs). We hypothesized that polymorphisms in HSF1 may alter the level or function of HSF1 protein accounting for interindividual viability in disease susceptibility or prognosis. We searched for exomic variants in HSF1 by querying human genome databases and directly sequencing DNA from 80 anonymous genomic DNA samples. Overall, HSF1 sequence was highly conserved, with no common variations. We found 31 validated deviations from a reference sequence in the dbSNP database and an additional 5 novel variants by sequencing, with allele frequencies that were 0.06 or less. Of these 36, 2 were in 5'-untranslated region (5'UTR), 10 in 3'UTR, and 24 in the coding region. The potential effects of 5'UTR on secondary structure, protein structure/function, and 3'UTR targets of microRNAs were analyzed using RNAFold, PolyPhen-2, SIFT, and MicroSNiper. One of the 5'UTR variants was predicted to strengthen secondary structure. Eight of 3'UTR variants were predicted to modify microRNA target sequences. Eight of the coding region variants were predicted to modify HSF1 structure/function. Reducing HSF1 levels in A549 cells using short hairpin RNA (shRNA) increased sensitivity to heat-induced killing demonstrating the impact that genetic variants that reduce HSF1 levels might have. Using the pmirGLO expression system, we found that the wild-type HSF1 3'UTR suppressed translation of a firefly luciferase reporter plasmid by 65 %. Introducing two of four 3'UTR single nucleotide polymorphisms (SNPs) increased HSF1 3'UTR translational suppression by 27-44 % compared with the wild-type HSF1 3'UTR sequence while a third SNP reduced suppression by 25 %. HSF1 variants may alter HSF1 protein levels or function with potential effects on cell functions, including sensitivity to stress.