Increased Neighborhood Deprivation Is Associated with Prolonged Hospital Stays After Surgical Fixation of Traumatic Pelvic Ring Injuries.

BACKGROUND: The purpose of this study was to understand the role of social determinants of health assessed by the Area Deprivation Index (ADI) on hospital length of stay and discharge destination following surgical fixation of pelvic ring fractures. METHODS: A retrospective chart analysis was performed for all patients who presented to our level-I trauma center with pelvic ring injuries that were treated with surgical fixation. Social determinants of health were determined via use of the ADI, a comprehensive metric of socioeconomic status, education, income, employment, and housing quality. ADI values range from 0 to 100 and are normalized to a U.S. mean of 50, with higher scores representing greater social deprivation. We stratified our cohort into 4 ADI quartiles. Statistical analysis was performed on the bottom (25th percentile and below, least deprived) and top (75th percentile and above, most deprived) ADI quartiles. Significance was set at p < 0.05. RESULTS: There were 134 patients who met the inclusion criteria. Patients in the most deprived group were significantly more likely to have a history of smoking, to self-identify as Black, and to have a lower mean household income (p = 0.001). The most deprived ADI quartile had a significantly longer mean length of stay (and standard deviation) (19.2 ± 19 days) compared with the least deprived ADI quartile (14.7 ± 11 days) (p = 0.04). The least deprived quartile had a significantly higher percentage of patients who were discharged to a resource-intensive skilled nursing facility or inpatient rehabilitation facility compared with those in the most deprived quartile (p = 0.04). Race, insurance, and income were not significant predictors of discharge destination or hospital length of stay. CONCLUSIONS: Patients facing greater social determinants of health had longer hospital stays and were less likely to be discharged to resource-intensive facilities when compared with patients of lesser social deprivation. This may be due to socioeconomic barriers that limit access to such facilities. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Closed Fracture Treatment in Adults, When is it Still Relevant?

INTRODUCTION: Fracture treatment has been documented since the times of ancient Egyptian and Greek civilization, with fracture reduction techniques and the apparatus for immobilization developed over three millennia. Over the last 150 years, aseptic technique, anesthesia, antibiotics, and internal implants have changed how orthopedic specialists approach fracture care. More recently, there has been an increased promotion in the medical literature to evaluate the clinical outcomes of nonsurgical treatment of common upper and lower extremity closed fractures. METHODS: In this paper, the authors review the history of closed extremity fracture treatments, outline contemporary studies regarding treatments of non-displaced fractures, and discuss the recent literature that has informed orthopedic surgeon-patient decision-making discussions regarding closed fracture management. CONCLUSIONS: Based on the results of this literature review, orthopedic providers should consider the preferable outcomes associated with nonoperative fracture management such as lower infection rates, the possibility of rapid functional improvements and lower healthcare costs. Nonoperative methods for closed fractures can sometimes be more safely delivered even with more difficult fractures. This may be of particular benefit to patients with higher surgical risks, minimizing exposure to treatments that are not only more invasive and expensive, but that can impose greater postoperative risks.

Comparing Postoperative Leg Length Discrepancy and Femoral Offset Using Two Different Surgical Approaches for Hemiarthroplasty of the Hip.

INTRODUCTION: The direct anterior approach (DAA) and anterolateral approach (ALA) may be used for hip hemiarthroplasty (HHA) as a treatment for femoral neck fractures. The DAA often utilizes intraoperative fluoroscopy to determine leg length and offset, while the ALA traditionally utilizes an intraoperative clinical exam to determine offset and leg length. This study will evaluate two techniques: the "grid fluoroscopy [GF] technique" and the "intraoperative exam [IE] technique," each performed by one of two separate surgeons, and compare each technique's accuracy to restore leg length and femoral offset in a patient population that underwent HHA. METHODS: Two investigators retrospectively reviewed charts of 208 randomly selected patients who had an HHA from either a DAA or ALA performed by two different surgeons for the treatment of femoral neck fractures. Postoperative AP pelvis radiographs were measured to determine offset and leg length compared with the non-operative extremity. Non-normal continuous variables were provided by median and interquartile range. Data were analyzed with the Mann-Whitney U test and Student's t-test. RESULTS: After inclusion and exclusion criteria, data were reviewed on 173 hemiarthroplasties. The mean age was 80.3 years (± 11.2 years). Of the surgical patients, 65.9% were female, and 70.9% identified their ethnicity as white. The DAA was used in 93 patients and ALA in 80 patients. Analysis comparing the two techniques demonstrated no statistically significant differences in median leg length between GF technique (1.02 IQR -0.1, 2.0 mm) and IE technique (1.25 IQR -2.4, 1.3 mm,) (p=0.67). There was also no statistically significant difference in offset between GF technique (1.3 IQR 0.2, 2.1 mm) and IE technique (0.6 IQR -2.7 mm, 3.2 mm) (p=0.13). However, a difference was found in mean length of surgery that was statistically significant. We found that the mean length of surgery for the IE technique was 74.8 ± 24.7 minutes versus the GF technique, which was 95.1 ± 23.0 minutes, (p<0.0001). DISCUSSION: There was no significant difference between leg length and offset with the use of intraoperative fluoroscopy with DAA compared to no intraoperative imaging with ALA. Our study suggests that DAA and ALA are equally effective approaches for re-establishing symmetric leg length and offset in HHA for femoral neck fractures. In this study, the ALA had a shorter surgical time compared to DAA, potentially due to the utilization of intraoperative fluoroscopy for this particular technique during the DAA.

High-Energy Blast Injury Requiring Transradial Amputation with Associated Essex Lopresti and Terrible Triad Injuries of the Elbow: A Rare Presentation.

CASE: Blast injuries to the upper extremity can be devastating and emotionally stressful injuries. We describe a case of a high-energy blast injury to an upper extremity from an explosive. The transfer of energy caused severe soft tissue/bony damage to the hand, but also led to associated Essex Lopresti and terrible triad injuries. The patient required emergent transradial amputation by hand surgery as well as definitive fixation by our orthopaedic team. CONCLUSION: We describe a unique salvage operation that established forearm pronosupination, elbow flexion, and proper prosthetic fitting. We feel that describing our technique could help others in treating this injury if encountered.

Motor Learning Consolidates Arc-Expressing Neuronal Ensembles in Secondary Motor Cortex.

Motor behaviors recruit task-specific neuronal ensembles in motor cortices, which are consolidated over subsequent learning. However, little is known about the molecules that can identify the participating neurons and predict the outcomes of the consolidation process. Using a mouse rotarod-learning task, we showed that lesion or inactivation of the secondary motor (M2) cortex disrupts learning of skilled movements. We tracked the endogenous promoter activity of the neuronal activity-regulated gene Arc in individual M2 neurons during rotarod learning by in vivo two-photon imaging of a knockin reporter. We found that task training initially recruits Arc-promoter-activated neurons and then consolidates them into a specific ensemble exhibiting persistent reactivation of Arc-promoter. The intensity of a neuron's initial Arc-promoter activation predicts its reactivation probability and neurons with weak initial Arc-promoter activation are dismissed from the ensemble during subsequent training. Our findings demonstrate a task-specific Arc-dependent cellular consolidation process in M2 cortex during motor learning.