High-Throughput Genomics Identify Novel FBN1/2 Variants in Severe Neonatal Marfan Syndrome and Congenital Heart Defects.

Fibrillin-1 and fibrillin-2, encoded by FBN1 and FBN2, respectively, play significant roles in elastic fiber assembly, with pathogenic variants causing a diverse group of connective tissue disorders such as Marfan syndrome (MFS) and congenital contractural arachnodactyly (CCD). Different genomic variations may lead to heterogeneous phenotypic features and functional consequences. Recent high-throughput sequencing modalities have allowed detection of novel variants that may guide the care for patients and inform the genetic counseling for their families. We performed clinical phenotyping for two newborn infants with complex congenital heart defects. For genetic investigations, we employed next-generation sequencing strategies including whole-genome Single-Nucleotide Polymorphism (SNP) microarray for infant A with valvular insufficiency, aortic sinus dilatation, hydronephrosis, and dysmorphic features, and Trio whole-exome sequencing (WES) for infant B with dextro-transposition of the great arteries (D-TGA) and both parents. Infant A is a term male with neonatal marfanoid features, left-sided hydronephrosis, and complex congenital heart defects including tricuspid regurgitation, aortic sinus dilatation, patent foramen ovale, patent ductus arteriosus, mitral regurgitation, tricuspid regurgitation, aortic regurgitation, and pulmonary sinus dilatation. He developed severe persistent pulmonary hypertension and worsening acute hypercapnic hypoxemic respiratory failure, and subsequently expired on day of life (DOL) 10 after compassionate extubation. Cytogenomic whole-genome SNP microarray analysis revealed a deletion within the FBN1 gene spanning exons 7-30, which overlapped with the exon deletion hotspot region associated with neonatal Marfan syndrome. Infant B is a term male prenatally diagnosed with isolated D-TGA. He required balloon atrial septostomy on DOL 0 and subsequent atrial switch operation, atrial septal defect repair, and patent ductus arteriosus ligation on DOL 5. Trio-WES revealed compound heterozygous c.518C>T and c.8230T>G variants in the FBN2 gene. Zygosity analysis confirmed each of the variants was inherited from one of the parents who were healthy heterozygous carriers. Since his cardiac repair at birth, he has been growing and developing well without any further hospitalization. Our study highlights novel FBN1/FBN2 variants and signifies the phenotype-genotype association in two infants affected with complex congenital heart defects with and without dysmorphic features. These findings speak to the importance of next-generation high-throughput genomics for novel variant detection and the phenotypic variability associated with FBN1/FBN2 variants, particularly in the neonatal period, which may significantly impact clinical care and family counseling.

Mapping Chromatin Occupancy of Ppp1r1b-lncRNA Genome-Wide Using Chromatin Isolation by RNA Purification (ChIRP)-seq.

Long non-coding RNA (lncRNA) mediated transcriptional regulation is increasingly recognized as an important gene regulatory mechanism during development and disease. LncRNAs are emerging as critical regulators of chromatin state; yet the nature and the extent of their interactions with chromatin remain to be fully revealed. We have previously identified Ppp1r1b-lncRNA as an essential epigenetic regulator of myogenic differentiation in cardiac and skeletal myocytes in mice and humans. We further demonstrated that Ppp1r1b-lncRNA function is mediated by the interaction with the chromatin-modifying complex polycomb repressive complex 2 (PRC2) at the promoter of myogenic differentiation transcription factors, TBX5 and MyoD1. Herein, we employed unbiased chromatin isolation by RNA purification (ChIRP) and high throughput sequencing to map the repertoire of Ppp1r1b-lncRNA chromatin occupancy genome-wide in the mouse muscle myoblast cell line. We uncovered a total of 99732 true peaks corresponding to Ppp1r1b-lncRNA binding sites at high confidence (p-value < 1E-5) and enrichment score ≥ 10). The Ppp1r1b-lncRNA-binding sites averaged 558 bp in length and were distributed widely within the coding and non-coding regions of the genome. Approximately 46% of these true peaks were mapped to gene elements, of which 1180 were mapped to experimentally validated promoter sequences. Importantly, the promoter-mapped binding sites were enriched in myogenic transcription factors and heart development while exhibiting focal interactions with known motifs of proximal promoters and transcription initiation by RNA Pol-II, including TATA-box, transcription initiator motif, CCAAT-box, and GC-box, supporting Ppp1r1b-lncRNA role in transcription initiation of myogenic regulators. Remarkably, nearly 40% of Ppp1r1b-lncRNA-binding sites mapped to gene introns were enriched with the Homeobox family of transcription factors and exhibited TA-rich motif sequences, suggesting potential motif-specific Ppp1r1b-lncRNA-bound introns. Lastly, more than 136521 enhancer sequences were detected in Ppp1r1b-lncRNA-occupancy sites at high confidence. Among these enhancers, 3390 (12%) exhibited cell type/tissue-specific enrichment in fetal heart and muscles. Together, our findings provide further insights into the genome-wide Ppp1r1b-lncRNA: Chromatin interactome that may dictate its function in myogenic differentiation and potentially other cellular and biological processes.

Mapping Chromatin Occupancy of Ppp1r1b-lncRNA Genome-Wide Using Chromatin Isolation by RNA Purification (ChIRP)-seq.

Long non-coding RNA (lncRNA) mediated transcriptional regulation is increasingly recognized as an important gene regulatory mechanism during development and disease. LncRNAs are emerging as critical regulators of chromatin state; yet the nature and the extent of their interactions with chromatin remain to be fully revealed. We have previously identified Ppp1r1b-lncRNA as an essential epigenetic regulator of myogenic differentiation in cardiac and skeletal myocytes in mice and humans. We further demonstrated that Ppp1r1b-lncRNA function is mediated by the interaction with the chromatin-modifying complex polycomb repressive complex 2 (PRC2) at the promoter of myogenic differentiation transcription factors, TBX5 and MyoD1. Herein, we employed an unbiased chromatin isolation by RNA purification (ChIRP) and high throughput sequencing to map the repertoire of Ppp1r1b-lncRNA chromatin occupancy genome-wide in the mouse muscle myoblast cell line. We uncovered a total of 99732 true peaks corresponding to Ppp1r1b-lncRNA binding sites at high confidence (P-value < 1e-5 and enrichment score ≥ 10). The Ppp1r1b-lncRNA-binding sites averaged 558 bp in length and were distributed widely within the coding and non-coding regions of the genome. Approximately 46% of these true peaks were mapped to gene elements, of which 1180 were mapped to experimentally validated promoter sequences. Importantly, the promoter-mapped binding sites were enriched in myogenic transcription factors and heart development while exhibiting focal interactions with known motifs of proximal promoters and transcription initiation by RNA polII, including TATA, transcription initiator, CCAAT-box, and GC-box, supporting Ppp1r1b-lncRNA role in transcription initiation of myogenic regulators. Remarkably, nearly 40% of Ppp1r1b-lncRNA-binding sites mapped to gene introns, were enriched with the Homeobox family of transcription factors, and exhibited TA-rich motif sequences, suggesting potential motif specific Ppp1r1b-lncRNA-bound introns. Lastly, more than 136521enhancer sequences were detected in Ppp1r1b-lncRNA-occupancy sites at high confidence. Among these enhancers,12% exhibited cell type/tissue-specific enrichment in fetal heart and muscles. Together, our findings provide further insights into the genome-wide Ppp1r1b-lncRNA: Chromatin interactome that may potentially dictate its function in myogenic differentiation and potentially other cellular and biological processes.

Pulmonary artery diameter correlates with echocardiographic parameters of right ventricular dysfunction in patients with acute pulmonary embolism.

Introduction: Right ventricular dysfunction (RVD) is a key component in the process of risk stratification in patients with acute pulmonary embolism (PE). Echocardiography remains the gold standard for RVD assessment, however, measures of RVD may be seen on CTPA imaging, including increased pulmonary artery diameter (PAD). The aim of our study was to evaluate the association between PAD and echocardiographic parameters of RVD in patients with acute PE. Methods: Retrospective analysis of patients diagnosed with acute PE was conducted at large academic center with an established pulmonary embolism response team (PERT). Patients with available clinical, imaging, and echocardiographic data were included. PAD was compared to echocardiographic markers of RVD. Statistical analysis was performed using the Student's t test, Chi-square test, or one-way analysis of variance (ANOVA); P < 0.05 was considered statistically significant. Results: 270 patients with acute PE were identified. Patients with a PAD >30 mm measured on CTPA had higher rates of RV dilation (73.1% vs 48.7%, P < 0.005), RV systolic dysfunction (65.4% vs 43.7%, P < 0.005), and RVSP >30 mmHg (90.2% vs 68%, P = 0.004), but not TAPSE ≤1.6 cm (39.1% vs 26.1%, P = 0.086). A weak increasing linear relationship between PAD and RVSP was noted (r = 0.379, P = 0.001). Conclusions: Increased PAD in patients with acute PE was significantly associated with echocardiographic markers of RVD. Increased PAD on CTPA in acute PE can serve as a rapid prognostic tool and assist with PE risk stratification at the time of diagnosis, allowing rapid mobilization of a PERT team and appropriate resource utilization.

Time is tissue. Want to save millions in wound care? Start early: a QI project to expedite referral of high-risk wound care patients to specialised care.

INTRODUCTION: Wound care is a multibillion-dollar industry, and most research and treatment are geared towards late-stage or end-stage care. The longer a patient has a wound, the more likely it is that complications (like sepsis or vascular compromise) will occur that will both extend treatment and multiply costs. We postulated that much of the suffering and healthcare costs of chronic wounds could be avoided by early identification of high-risk patients and subsequent earlier intervention. In an established regional wound clinic, our aim was to decrease referral times by 50% within 1 year, and to demonstrate the beneficial outcomes on wound healing and total cost of care. METHODS: A prospective interventional quality improvement study was performed between June 2017 and June 2018. We determined baseline referral times to the clinic and then performed three interventions. The effects on referral time, healing time and number of home care visits to achieve wound healing were collected and displayed on annotated control charts. The cost of care and potential for cost avoidance was determined by an analysis of the medical encounters of twenty chronic wound patients. RESULTS: We achieved a 53.6% reduction in average referral times to the clinic, a 59.6% reduction in average healing times and a 66.0% reduction in the average number of home care visits required to achieve healing. Our cost analysis suggested the potential for significant cost avoidance (87.7%) compared with delayed treatment outside the clinic. CONCLUSIONS: Early identification and treatment of patients at high risk for wound chronicity and complications, followed by early referral to and treatment at a specialised wound clinic, resulted in faster healing and reduced health system costs.

Impact of the COVID-19 Pandemic on Orthopedic Surgery Residency Training.

This study sought to investigate the impact of the coronavirus disease 2019 (COVID-19) pandemic on orthopedic surgery residency training across the United States. A 26-question online survey was created and sent to all orthopedic surgery residency programs across the United States. Areas of emphasis in the survey included the pandemic's effect on work hours, operative experience, didactics, and medical student recruitment. There were 142 respondents to the survey. One hundred seventeen (82.4%) respondents stated that their residency changed to an alternative/surge schedule during the pandemic. Regarding the degree to which the pandemic affected their training, 77 (54.2%) respondents gave a rating of 8 to 10 on a scale of 0 to 10. Similarly, 94 (66.2%) residents indicated that their operative experience had decreased significantly. Twenty-two (15.5%) residents expected that their next year clinical abilities would not be affected. One hundred thirty-seven (96.5%) residents stated their program transitioned to online didactics. Responses regarding the effectiveness of online didactics were mixed. One hundred twenty-six (88.7%) respondents stated the pandemic would negatively affect the 2021 National Residency Matching Program match. This study demonstrated that the COVID-19 pandemic greatly affected orthopedic surgery residency training in the United States. Resident operative experience decreased significantly, and most respondents indicated a switch to online didactics. Effects were also felt to extend to fourth-year scheduling and the 2021 National Residency Matching Program match. [Orthopedics. 2023;46(5):315-319.].

Outpatient Treatment Guidelines of Gunshot Wound to the Hand and Wrist Resulting in an Open Fracture: Case Report.

The incidence of non-fatal gunshot wounds has significantly increased in the past decade. The current guidelines lack clarity in treatment of bullet wounds to the hand and wrist. An 18-year-old male presented to the emergency department with a gunshot wound to the hand/wrist resulting in an open fracture. The entrance wound was clean without visible bone. No neurovascular damage was reported. The wound was irrigated with saline, and a sterile dressing and splint was applied in the emergency department. The patient was discharged the same day with oral antibiotics and an appointment with an orthopedic hand specialist. Three days after the injury, the patient was taken to surgery to treat a fracture of the radius and lunate. No internal fixation was required. The fracture and bullet fragments were removed, and the patient was discharged on the same day. The patient recovered to a full range of motion and no infection was acquired throughout treatment and healing.  The current guidelines for the treatment and management of nonfatal gunshot wounds to the hand and wrist are inconsistent resulting in unnecessary admittance to the hospital. Our paper provides a template for future cases allowing for outpatient treatment.

Hickam's dictum, Occam's razor, and Crabtree's bludgeon: a case of renal failure and a clavicular mass.

OBJECTIVES: Our discussant's thoughtful consideration of the patient's case allows for review of three maxims of medicine: Occam's razor (the simplest diagnosis is the most likely to be correct), Hickam's dictum (multiple disease entities are more likely than one), and Crabtree's bludgeon (the tendency to make data fit to an explanation we hold dear). CASE PRESENTATION: A 66-year-old woman with a history of hypertension presented to our hospital one day after arrival to the United States from Guinea with chronic daily vomiting, unintentional weight loss and progressive shoulder pain. Her labs are notable for renal failure, nephrotic range proteinuria and normocytic anemia while her shoulder X-ray shows osseous resorption in the lateral right clavicle. Multiple myeloma became the team's working diagnosis; however, a subsequent shoulder biopsy was consistent with follicular thyroid carcinoma. Imaging suggested the patient's renal failure was more likely a result of a chronic, unrelated process. CONCLUSIONS: It is tempting to bludgeon diagnostic possibilities into Occam's razor. Presumption that a patient's signs and symptoms are connected by one disease process often puts us at a cognitive advantage. However, atypical presentations, multiple disease processes, and unique populations often lend themselves more to Hickam's dictum than to Occam's razor. Diagnostic aids include performing a metacognitive checklist, engaging analytic thinking, and acknowledging the imperfections of these axioms.

Cigarette Smoke Exposure Promotes Virulence of Pseudomonas aeruginosa and Induces Resistance to Neutrophil Killing.

It is widely known that cigarette smoke damages host defenses and increases susceptibility to bacterial infections. Pseudomonas aeruginosa, a Gram-negative bacterium that commonly colonizes the airways of smokers and patients with chronic lung disease, can cause pneumonia and sepsis and can trigger exacerbations of lung diseases. Pseudomonas aeruginosa colonizing airways is consistently exposed to inhaled cigarette smoke. Here, we investigated whether cigarette smoke alters the ability of this clinically significant microbe to bypass host defenses and cause invasive disease. We found that cigarette smoke extract (CSE) exposure enhances resistance to human neutrophil killing, but this increase in pathogenicity was not due to resistance to neutrophil extracellular traps. Instead, Pseudomonas aeruginosa exposed to CSE (CSE-PSA) had increased resistance to oxidative stress, which correlated with increased expression of tpx, a gene essential for defense against oxidative stress. In addition, exposure to CSE induced enhanced biofilm formation and resistance to the antibiotic levofloxacin. Finally, CSE-PSA had increased virulence in a model of pneumonia, with 0% of mice infected with CSE-PSA alive at day 6, while 28% of controls survived. Altogether, these data show that cigarette smoke alters the phenotype of P. aeruginosa, increasing virulence and making it less susceptible to killing by neutrophils and more capable of causing invasive disease. These findings provide further explanation of the refractory nature of respiratory illnesses in smokers and highlight cigarette smoking as a potential driver of virulence in this important airway pathogen.

Virtual Reality and Augmented Reality-Translating Surgical Training into Surgical Technique.

PURPOSE OF REVIEW: As immersive learning outside of the operating room is increasingly recognized as a valuable method of surgical training, virtual reality (VR) and augmented reality (AR) are increasingly utilized in orthopedic surgical training. This article reviews the evolving nature of these training tools and provides examples of their use and efficacy. The practical and ethical implications of incorporating this technology and its impact on both orthopedic surgeons and their patients are also discussed. RECENT FINDINGS: Head-mounted displays (HMDs) represent a possible adjunct to surgical accuracy and education. While the hardware is advanced, there is still much work to be done in developing software that allows for seamless, reliable, useful integration into clinical practice and training. Surgical training is changing: AR and VR will become mainstays of future training efforts. More evidence is needed to determine which training technology translates to improved clinical performance. Volatility within the HMD industry will likely delay advances in surgical training.

Physiologic widening of the medial clear space: What's normal?

BACKGROUND: Literature has validated the use of stress radiographs for evaluation of ankle stability. However, to our knowledge no study has reported the amount of physiological widening that occurs with manual external rotation stress test in uninjured ankles. The purpose of this study was to assess the amount of medial clear space widening that occurs with a manual external rotation stress test in uninjured ankles. METHODS: A cohort of adult patients undergoing operative fixation of unstable ankle fractures were prospectively enrolled to have their contralateral ankle undergo manual external rotation stress examination. Fluoroscopic images of the unaffected ankle were performed in the OR. A non-stressed mortise view and manual external rotation stress view were obtained with a standardized marker to correct for magnification differences. The images were de-identified, presented in a randomized order and reviewers who were blinded. Each reviewer measured the medial clear space. RESULTS: Thirty fluoroscopic images on fifteen patients were obtained. The mean medial clear space on the non-stressed mortise view was 3.1 mm (SD-0.69; Range 1.9 to 4.2, 95% CI [2.75, 3.45]) versus a mean of 3.2 mm (SD-0.71; Range 2.0 to 4.7, 95% CI [2.94, 3.66]) in the stressed mortise view group. Inter-rater reliability was excellent between all observers for medial clear space (ICC-0.88; CI [0.78, 0.94]). CONCLUSIONS: Our results support the previous literature and allow us to advocate for ankle fractures with >5 mm medial clear space after external rotational stress to be considered unstable. Additionally, ankles with a medial clear space between 4 and 5 mm, instability should be considered only if lateral shift is > 2 mm on stress examination. Our data shows that no physiologically healthy ankles widened beyond these established cut-offs before or after the manual external rotation stress.

Plantar Medial Avulsion Fragment Associated With Tongue-Type Calcaneus Fractures.

BACKGROUND: The plantar fascia attaches to the tuberosity of the calcaneus, which produces a distinct plantar medial avulsion (PMA) fracture fragment in certain calcaneal fractures. We hypothesized that tongue-type fractures, as described by the Essex-Lopresti classification, were more likely to be associated with this PMA fracture than joint depression fractures. METHODS: A retrospective chart review was performed at 2 distinct Level I trauma centers to identify patients sustaining calcaneal fractures. Radiographs were then reviewed to determine the Essex-Lopresti classification, OTA classification, and presence of a PMA fracture. RESULTS: The review yielded 271 total patients with 121 (44.6%) tongue-type (TT), 110 (40.6%) joint depression (JD), and 40 (14.8%) fractures not classifiable by the Essex-Lopresti classification. In the TT group, 73.6% of the patients had the PMA fracture whereas only 8.2% of JD and 15.0% of nonclassifiable fractures demonstrated a PMA fragment ( P < .001). CONCLUSION: Plantar medial avulsion fractures occurred in 38.4% of the calcaneal fractures reviewed with a significantly greater proportion occurring in TT (73.6%) as opposed to JD (8.2%). Given the plantar fascia attachment to the PMA fragment, there may be clinical significance to identifying this fracture and changing treatment management; however, this requires further investigation. LEVEL OF EVIDENCE: Level III, comparative study.

Dealing with the loss of a resident: An analysis of burnout rates in a reduced complement training program.

BACKGROUND: Residents in all fields of medicine experience high levels of burnout and less job-related satisfaction due to the stress experienced during training. Reduced complement residency classes often experience increased workloads due to the need to compensate for the fewer number of classmates. OBJECTIVE: The goal of this study was to examine whether residency classes of reduced size experience higher levels of burnout. METHODS: The Maslach Burnout Inventory Survey was distributed to all orthopaedic residents at our institution for four consecutive years. Emotional exhaustion≥27 and depersonalization≥10 correlate with high levels of burnout. At our institution, two residents were lost during their second year of training. Group 1 (n = 56) consisted of residents with reduced-size classes, while group 2 (n = 60) consisted of residents with full complement classes. RESULTS: Mean emotional exhaustion (29 vs. 30) and depersonalization (17 vs. 17) scores were comparable between reduced and full complement classes. The Maslach data from our study showed no statistical difference in burnout levels between classes of full complement and reduced complement. CONCLUSIONS: When compared to a previous study on burnout conducted in large orthopaedic residency programs, our entire residency program did demonstrate similar levels of emotional exhaustion and depersonalization.

Concomitant Proximal and Distal Tibiofibular Joint Dislocation Associated With a Tibial Shaft Fracture.

An association exists between tibial shaft fractures and ankle injuries. In addition, although uncommon, an association between tibial shaft fractures and proximal tibiofibular dislocations has also been established. A review of the previous literature resulted in one case report of a complete proximal and distal tibiofibular joint dislocation without fracture of the tibia or fibula. Here, we discuss a case of a complete proximal and distal tibiofibular syndesmotic complex dislocation associated with a tibial shaft fracture. To the best of our knowledge, this is the first report of this injury pattern associated with a tibial shaft fracture.

Safe Zone Quantification of the Third Sacral Segment in Normal and Dysmorphic Sacra.

OBJECTIVE: To quantify the osseous anatomy of the dysmorphic third sacral segment and assess its ability to accommodate internal fixation. DESIGN: Retrospective chart review of a trauma database. SETTING: University Level 1 Trauma Center. PATIENTS: Fifty-nine patients over the age of 18 with computed tomography scans of the pelvis separated into 2 groups: a group with normal pelvic anatomy and a group with sacral dysmorphism. MAIN OUTCOME MEASUREMENTS: The sacral osseous area was measured on computed tomography scans in the axial, coronal, and sagittal planes in normal and dysmorphic pelves. These measurements were used to determine the possibility of accommodating a transiliac transsacral screw in the third sacral segment. RESULTS: In the normal group, the S3 coronal transverse width averaged 7.71 mm and the S3 axial transverse width averaged 7.12 mm. The mean S3 cross-sectional area of the normal group was 55.8 mm. The dysmorphic group was found to have a mean S3 coronal transverse width of 9.49 mm, an average S3 axial transverse width of 9.14 mm, and an S3 cross-sectional area of 77.9 mm. CONCLUSIONS: The third sacral segment of dysmorphic sacra has a larger osseous pathway available to safely accommodate a transiliac transsacral screw when compared with normal sacra. The S3 segment of dysmorphic sacra can serve as an additional site for screw placement when treating unstable posterior pelvic ring fractures.

The Correlation Between the OTA/AO Classification System and Compartment Syndrome in Both Bone Forearm Fractures.

OBJECTIVE: To evaluate the efficacy of using the Orthopaedic Trauma Association (OTA/AO) classification for both bone forearm fractures in predicting compartment syndrome. DESIGN: Retrospective cohort. SETTING: Level 1 Academic Trauma Center. PATIENTS/PARTICIPANTS: One hundred fifty-one patients 18 years of age and older, with both bone forearm fractures diagnosed from 2001 to 2016 were categorized based on the OTA/AO classification. Patients with both bone fractures caused by gunshot wounds were excluded. MAIN OUTCOME MEASUREMENTS: The endpoint for our study was whether forearm fasciotomies were performed based on the presence of compartment syndrome. RESULTS: Of a total of 151 both bone forearm fractures, 15% underwent fasciotomy. Six of 80 (7.5%) grouped 22-A3, 8 of 44 (18%) grouped 22-B3, and 9 of 27 (33%) grouped 22-C underwent fasciotomies for compartment syndrome (P = 0.004). The relative risks of developing compartment syndrome for group 22-B3 versus 22-A3 was 2.42 (P = 0.08), 22-C versus 22-B3 was 1.83 (P = 0.15), and 22-C versus 22-A3 was 4.44 (P = 0.002). CONCLUSIONS: There is a significant correlation between the OTA/AO classification and the need for fasciotomies, with group C fractures representing the highest risk. Clinicians can use this information to have a higher index of suspicion for compartment syndrome based on OTA/AO classification to help minimize the risk of a missed diagnosis. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The role of computed tomography scans in diaphyseal femur fractures following gunshot injuries: A survey of orthopaedic traumatologists.

The objective of this study was to analyze if the addition of CT changed the management of femoral shaft fractures caused by gunshot wounds when compared to those managed with plain radiography alone. METHODS: A multiple-choice, single-answer electronic survey was created to compare utility of advanced imaging when treating femur fractures resulting from gunshot injury. A total of ten femoral shaft fracture cause by gunshot injuries were selected for an online survey to be administered to orthopeaedic traumatologists. The survey compared the use the of fixation device and surgical planning before and after the CT scan. RESULTS: A total of 99 surveys were initiated, of which 82 were completed. For proximal shaft fractures, 37% of experts reported that a CT scan should be ordered based on the radiograph alone, prior to reviewing the CT. After reviewing the CT, 5% of experts reported that they would have performed a "major" change, and 10% reported that they would have performed a "minor" change. 4% of surveyors would have changed their decision regarding ordering a CT. For distal femoral shaft fractures, 42% of experts selected that a CT scan would have been ordered prior to reviewing the CT. After reviewing the CT, 2% would have performed a "major" change, and 8% would have performed a "minor" change in management. 5% of surveyors would have changed their decision regarding ordering a CT. CONCLUSION: Our study demonstrated that CT scans are relatively unlikely to cause major changes in fracture management of gunshot-induced fractures of femoral shaft.

The Antibiotic Nail in the Treatment of Long Bone Infection: Technique and Results.

Antibiotic cement nails provide a useful and relatively simple technique to treat intramedullary osteomyelitis of the long bones. These devices provide stability as well as local, targeted antibiotics, which are both critical aspects of osteomyelitis management. Additionally, the use of a threaded core is a critical component of successful cement nail assembly. With adherence to the simple principles outlined in this review, surgeons can expect reliably good results using these drug-delivery implants.

Trends in Vitreoretinal Procedures for Medicare Beneficiaries, 2000 to 2014.

TOPIC: The purpose of this study was to identify changes in use for vitreoretinal procedures by measuring the number of allowed services using data from the US Medicare Part B Fee-for-Service (FFS) beneficiaries and their providers. CLINICAL RELEVANCE: To analyze vitreoretinal procedural trends, which may indicate standard of care and importance of developing methods of treatments. METHODS: Medicare Part B National Summary Data Files for calendar years 2000 to 2014 were used to identify the number of allowed services for vitreoretinal procedures and commonly used pharmacologic agents. Linear regression analysis was performed to identify trends in use. MAIN OUTCOME MEASURES: To analyze vitreoretinal procedural trends, which may indicate standard of care and importance of developing methods of treatments. RESULTS: Vitreoretinal procedures grew 6-fold from 2000 to 2014. Intravitreal injections were the primary driver of growth. A total of 2922 injections were performed in 2000, compared with 2 619 950 injections in 2014 (P < 0.01). Scleral buckling declined from 6502 procedures in 2000 to 1260 procedures in 2014 (P < 0.01), whereas vitrectomy use for retinal detachment increased from 13 814 surgeries in 2008 to 19 288 surgeries in 2014 (P < 0.01). Focal laser treatments declined from 188 351 procedures in 2002 to 83 379 procedures in 2014 (P < 0.01). Panretinal photocoagulation treatments declined from 109 840 procedures in 2004 to 81 005 procedures in 2014 (P < 0.01). CONCLUSIONS: Vitreoretinal practice patterns changed significantly from 2000 to 2014. Intravitreal injections increased by 89 563%. Intravitreal injections accounted for 0.55% of all vitreoretinal procedures in 2000 and increased to 87% in 2014. Scleral buckling sharply declined, and preference for retinal detachment repair shifted further toward vitrectomy with a distribution of 83% vitrectomy, 5% scleral buckling, and 12% pneumatic retinopexy in 2014. Use of laser photocoagulation significantly declined for treatment of macular edema and proliferative retinopathy. Cryotherapy procedures declined across all indications.

Evaluation of Intra-articular Fracture Extension After Gunshot Wounds to the Lower Extremity: Plain Radiographs Versus Computer Tomography.

OBJECTIVE: This study was to compare the use of computer tomography with plain radiographs for the evaluation of intra-articular extension of long bone fractures in the lower extremity after low-energy gunshot wounds. DESIGN: Retrospective chart and radiographic review. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Data were collected from a single institution from 2000 to 2014. Inclusion criteria consisted of patients greater than 17 years of age, low-velocity gunshot injuries causing fracture of the femur or tibia, plain radiographs with adequate films, and computed tomography (CT) imaging of the fracture. This consisted of 133 patients with 140 fractures. INTERVENTION: Intra-articular fracture extension was evaluated on initial plain radiographs and CTs. MAIN OUTCOME MEASURES: Comparison of "gold standard" CT with all reviewers' evaluation of plain radiographs. RESULTS: There were 140 total fractures; 108 were femoral fractures and 32 were tibial fractures. By comparing plain radiographs with the gold standard CT, the reviewers demonstrated correct diagnosis in 85% of intra-articular fractures and 96% of non-intra-articular fractures. In addition, the reviewers accurately diagnosed 70.8% of intra-articular extensions in the diaphysis and 70.5% in the metaphysis. The sensitivity and specificity for plain radiographs were 85.3% and 96.0%, respectively, for all locations. Metaphyseal and diaphyseal fractures demonstrated the poorest sensitivity at 80.7% and 82.1%, respectively. CONCLUSIONS: Low-energy gunshot wounds with fractures in the diaphyseal of the distal femur and all metaphyseal fractures warrant CT evaluation to better examine for intra-articular fracture extension. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.