Efficacy of post-operative X-rays after operatively treated ankle fractures: What is their role?

OBJECTIVE: The utility of routine post-operative imaging in clinically asymptomatic patients is unclear. We sought to determine how frequently X-rays following operatively treated ankle fractures result in a change in management. DESIGN: Retrospective cohort study conducted with hospital electronic health record SETTING: Single level 1 trauma center in major urban city. PATIENTS/PARTICIPANTS: 193 patients with operatively treated ankle fractures at our institution between January 2020 and December 2021. MAIN OUTCOME MEASURES: Patient radiographs were categorized as surveillance X-rays and clinically indicated X-rays. Changes in management were defined as alteration in follow-up, deviation from standard post-operative protocols, or revision surgery. A logistic regression was performed looking at factors predicting whether an X-ray changes management. A cost analysis was also performed looking at the financial implications of asymptomatic surveillance of ankle fractures. RESULTS: 438 post-operative X-rays were found and included in analysis. Of these, 391 were considered surveillance X-rays and 47 clinically indicated. 23 X-rays were determined to have resulted in changes in management (18 clinically indicated, 5 taken in asymptomatic patients). The number of management changing X-rays was significantly higher in the clinically indicated group (p < 0.0001). The only factor associated with whether an X-ray changed management was whether the patient was symptomatic at the visit (p < 0.0001). Asymptomatic surveillance X-rays cost our institution 21,825.62 USD per year. CONCLUSIONS: Radiographs in clinically asymptomatic patients with operatively managed ankle fractures have a low likelihood of changing management. Such imaging represents costs to the healthcare system, increased time for patients during clinic visits, and radiation exposure. The use of screening radiographic studies remains commonplace because the risk of delayed diagnosis is great, and the goal of any surgeon should be the swift identification of complications in order to minimize patient morbidity. Future surveillance protocols should consider the findings of this and other studies on the use of screening radiographs and strike a careful balance between minimizing unnecessary imaging, maximizing early complication detection, and ensuring a personalized approach towards patient-level factors to optimize care and efficiency for both patient and health system. LEVEL OF EVIDENCE: Level III.

Forgetting the Frail: National Trends in Vitamin D Prescription After Fragility Fracture-A Large Insurance Claims Database Study.

INTRODUCTION: Vitamin D plays a critical role in bone health, affecting bone mineral density and fracture healing. Insufficient serum vitamin D levels are associated with increased fracture rates. Despite guidelines advocating vitamin D supplementation, little is known about the prescription rates after fragility fractures. This study aims to characterize vitamin D prescription rates after three common fragility fractures in patients older than 50 years and explore potential factors influencing prescription rates. METHODS: The study used the PearlDiver Database, identifying patients older than 50 years with hip fractures, spinal compression fractures, or distal radius fractures between 2010 and 2020. Patient demographics, comorbidities, and vitamin D prescription rates were analyzed. Statistical methods included chi-square analysis and univariate and multivariable analyses. RESULTS: A total of 3,214,294 patients with fragility fractures were included. Vitamin D prescriptions increased from 2.50% to nearly 6% for all fracture types from 2010 to 2020. Regional variations existed, with the Midwest having the highest prescription rate (4.25%) and the West the lowest (3.31%). Patients with comorbidities such as diabetes, tobacco use, obesity, female sex, age older than 60 years, and osteoporosis were more likely to receive vitamin D prescriptions. DISCUSSION: Despite a notable increase in vitamin D prescriptions after fragility fractures, the absolute rates remain low. Patient comorbidities influenced prescription rates, perhaps indicating growing awareness of the link between vitamin D deficiency and these conditions. However, individuals older than 60 years, a high-risk group, were markedly less likely to receive prescriptions, possibly because of practice variations and concerns about polypharmacy. Educational initiatives and revised guidelines may have improved vitamin D prescription rates after fragility fractures. However, there is a need to raise awareness about the importance of vitamin D for bone health, particularly in older adults, and additional study variations in prescription practices. These findings emphasize the importance of enhancing post-fracture care to reduce morbidity and mortality associated with fragility fractures. LEVEL OF EVIDENCE: III.

Management of ACL Reconstruction Complicated by MRSA Osteomyelitis Requiring a Gastrocnemius Perforator Flap: A Case Report.

CASE: A 21-year-old woman presented with sepsis from methicillin-resistant Staphylococcus aureus, patellar osteomyelitis, and 6 × 4 × 2-cm proximal anteromedial soft-tissue defect 1 week after bone-tendon-bone autograft anterior cruciate ligament reconstruction (ACL-R). She underwent multiple irrigation and debridement (I&Ds), hardware removal, bone grafting with antibiotic-loaded tricalcium phosphate beads, and medial gastrocnemius perforator flap with plastic surgery. At 18 months after her initial ACL-R, single-stage revision ACL-R with quadriceps autograft was performed. CONCLUSION: When acute ACL-R infection does not respond to initial I&D and Intravenous (IV) antibiotics, retained hardware and graft tissue must be removed expeditiously to prevent sepsis, osteomyelitis, and soft-tissue defects.

Non-classical Celiac Disease as an Unrecognized Cause for Post-operative Knee Swelling following Patellofemoral Arthroplasty: A Case Report.

Introduction: Non-classical Celiac disease is a previously undescribed cause of debilitating post-operative cutaneous complications following an orthopedic procedure. Non-specific symptoms and rarity of the disease pose a diagnostic challenge; however, given underdiagnosis and significant morbidity, after ruling out of acute pathology, Celiac disease should be included in differential diagnosis for refractory cutaneous complications following an operative procedure. Case Report: A 34-year-old woman who underwent patellofemoral arthroplasty and medial patellofemoral ligament reconstruction experienced over 5 months of post-operative knee swelling, erythema, and pain unresponsive to antihistamines and negative infectious, vascular, and implant allergy testing workups. After careful dietary monitoring by an allergy specialist, she was tested and confirmed to have Celiac disease. Following cessation of her oral contraceptive pill and dietary gluten, her knee swelling, erythema, and debilitating pain resolved. Conclusion: Skin erythema, swelling, and pain are known complications after any operative treatment, but after ruling out of acute infectious and thromboembolic processes, diagnosis and management of refractory complications pose a challenging scenario. In this rare phenomenon, previously undescribed, a patient presented with months of post-operative knee erythema, swelling, stiffness, and extreme pain on activity along with non-specific symptoms of headache and fatigue before diagnosis with Celiac disease. On cessation of her birth control and dietary gluten, her symptoms and knee function improved dramatically.

Editorial Commentary: Machine Learning and Artificial Intelligence Are Tools Requiring Physician and Patient Input When Screening Patients at Risk for Extended, Postoperative Opioid Use.

As the implementation of artificial intelligence in orthopedic surgery research flourishes, so grows the need for responsible use. Related research requires clear reporting of algorithmic error rates. Recent studies show that preoperative opioid use, male sex, and greater body mass index are risk factors for extended, postoperative opioid use, but may result in high false positive rates. Thus, to be applied clinically when screening patients, these tools require physician and patient input, and nuanced interpretation, as the utility of these screening tools diminish without providers interpreting and acting on the information. Machine learning and artificial intelligence should be viewed as tools that can facilitate these human conversations among patients, orthopedic surgeons, and health care providers.

The Effect of Normothermic Machine Perfusion on the Immune Profile of Donor Liver.

Background: Normothermic machine perfusion (NMP) allows viability assessment and potential resuscitation of donor livers prior to transplantation. The immunological effect of NMP on liver allografts is undetermined, with potential implications on allograft function, rejection outcomes and overall survival. In this study we define the changes in immune profile of human livers during NMP. Methods: Six human livers were placed on a NMP device. Tissue and perfusate samples were obtained during cold storage prior to perfusion and at 1, 3, and 6 hours of perfusion. Flow cytometry, immunohistochemistry, and bead-based immunoassays were used to measure leukocyte composition and cytokines in the perfusate and within the liver tissue. Mean values between baseline and time points were compared by Student's t-test. Results: Within circulating perfusate, significantly increased frequencies of CD4 T cells, B cells and eosinophils were detectable by 1 hour of NMP and continued to increase at 6 hours of perfusion. On the other hand, NK cell frequency significantly decreased by 1 hour of NMP and remained decreased for the duration of perfusion. Within the liver tissue there was significantly increased B cell frequency but decreased neutrophils detectable at 6 hours of NMP. A transient decrease in intermediate monocyte frequency was detectable in liver tissue during the middle of the perfusion run. Overall, no significant differences were detectable in tissue resident T regulatory cells during NMP. Significantly increased levels of pro-inflammatory and anti-inflammatory cytokines were seen following initiation of NMP that continued to rise throughout duration of perfusion. Conclusions: Time-dependent dynamic changes are seen in individual leukocyte cell-types within both perfusate and tissue compartments of donor livers during NMP. This suggests a potential role of NMP in altering the immunogenicity of donor livers prior to transplant. These data also provide insights for future work to recondition the intrinsic immune profile of donor livers during NMP prior to transplantation.

Donor leukocyte trafficking during human ex vivo lung perfusion.

BACKGROUND: Ex vivo lung perfusion (EVLP) is used to assess and preserve lungs prior to transplantation. However, its inherent immunomodulatory effects are not completely understood. We examine perfusate and tissue compartments to determine the change in immune cell composition in human lungs maintained on EVLP. METHODS: Six human lungs unsuitable for transplantation underwent EVLP. Tissue and perfusate samples were obtained during cold storage and at 1-, 3- and 6-h during perfusion. Flow cytometry, immunohistochemistry, and bead-based immunoassays were used to measure leukocyte composition and cytokines. Mean values between baseline and time points were compared by Student's t test. RESULTS: During the 1st hour of perfusion, perfusate neutrophils increased (+22.2 ± 13.5%, p < 0.05), monocytes decreased (-77.5 ± 8.6%, p < 0.01) and NK cells decreased (-61.5 ± 22.6%, p < 0.01) compared to cold storage. In contrast, tissue neutrophils decreased (-22.1 ± 12.2%, p < 0.05) with no change in monocytes and NK cells. By 6 h, perfusate neutrophils, NK cells, and tissue neutrophils were similar to baseline. Perfusate monocytes remained decreased, while tissue monocytes remained unchanged. There was no significant change in B cells or T cell subsets. Pro-inflammatory cytokines (IL-1b, G-CSF, IFN-gamma, CXCL2, CXCL1 granzyme A, and granzyme B) and lymphocyte activating cytokines (IL-2, IL-4, IL-6, IL-8) increased during perfusion. CONCLUSIONS: Early mobilization of innate immune cells occurs in both perfusate and tissue compartments during EVLP, with neutrophils and NK cells returning to baseline and monocytes remaining depleted after 6 h. The immunomodulatory effect of EVLP may provide a therapeutic window to decrease the immunogenicity of lungs prior to transplantation.

Nanotraps for the containment and clearance of SARS-CoV-2.

SARS-CoV-2 enters host cells through its viral spike protein binding to angiotensin-converting enzyme 2 (ACE2) receptors on the host cells. Here, we show that functionalized nanoparticles, termed "Nanotraps," completely inhibited SARS-CoV-2 infection by blocking the interaction between the spike protein of SARS-CoV-2 and the ACE2 of host cells. The liposomal-based Nanotrap surfaces were functionalized with either recombinant ACE2 proteins or anti-SARS-CoV-2 neutralizing antibodies and phagocytosis-specific phosphatidylserines. The Nanotraps effectively captured SARS-CoV-2 and completely blocked SARS-CoV-2 infection to ACE2-expressing human cell lines and primary lung cells; the phosphatidylserine triggered subsequent phagocytosis of the virus-bound, biodegradable Nanotraps by macrophages, leading to the clearance of pseudotyped and authentic virus in vitro. Furthermore, the Nanotraps demonstrated an excellent biosafety profile in vitro and in vivo. Finally, the Nanotraps inhibited pseudotyped SARS-CoV-2 infection in live human lungs in an ex vivo lung perfusion system. In summary, Nanotraps represent a new nanomedicine for the inhibition of SARS-CoV-2 infection.