Patient Utilization of Online Information and its Influence on Orthopedic Surgeon Selection: Cross-sectional Survey of Patient Beliefs and Behaviors.

BACKGROUND: Patient attitudes and behavior are critical to understand owing to the increasing role of patient choice. There is a paucity of investigation into the perceived credibility of online information and whether such information impacts how patients choose their surgeons. OBJECTIVE: The purpose of this study was to explore the attitudes and behavior of patients regarding online information and orthopedic surgeon selection. Secondary purposes included gaining insight into the relative importance of provider selection factors, and their association with patient age and education level. METHODS: This was a cross-sectional study involving five multispecialty orthopedic surgery groups. A total of 329 patients who sought treatment by six different orthopedic surgeons were asked to anonymously answer a questionnaire consisting of 25 questions. Four questions regarded demographic information, 10 questions asked patients to rate the importance of specific criteria regarding the selection of their orthopedic surgeon (on a 4-point Likert scale), and 6 questions were designed to determine patient attitude and behaviors related to online information. RESULTS: Patient-reported referral sources included the emergency room (29/329, 8.8%), friend (42/329, 12.8%), insurance company (47/329, 14.3%), internet search/website (28/329, 8.5%), primary care physician (148/329, 45.0%), and other (34/329, 10.3%). Among the 329 patients, 130 (39.5%) reported that they searched the internet for information before their first visit. There was a trend of increased belief in online information to be accurate and complete in younger age groups (P=.02). There was an increased relative frequency in younger groups to perceive physician rating websites to be unbiased (P=.003), provide sufficient patient satisfaction information (P=.01), and information about physician education and training (P=.03). There was a significant trend for patients that found a surgeon's website to be useful (P<.001), with the relative frequency increased in younger age groups. CONCLUSIONS: This study shows that insurance network, physician referrals, appointment availability, and office location are important to patients, whereas advertising and internet reviews by other patients were considered to be not as helpful in choosing an orthopedic surgeon. Future studies may seek to identify obstacles to patients in integrating online resources for decision-making and strategies to improve health-seeking behaviors.

Unusual cause of gas complicating a biloma, postcholecystectomy.

A 50-year-old man presented to the emergency department with abdominal pain, vomiting and fever. He had been admitted 6 months ago with acute cholecystitis when he underwent endoscopic retrograde cholangiopancreatography (ERCP) to remove ductal gallstones. Elective cholecystectomy was performed 3 days prior to the current admission. CT demonstrated a fluid and gas containing collection in the gallbladder fossa, biliary gas and free intra-abdominal gas. ERCP revealed a retained common bile duct gallstone and leakage from the cystic duct remnant. We postulate that the gas within the collection originated from intrahepatic gas post-ERCP or from a gas forming organism. The free intra-abdominal gas originated from the collection rather than an intraoperative bowel injury. This complicated case highlights an unusual appearance of a common complication. It demonstrates the importance of discussion with the clinical team to ensure that an accurate diagnosis is made and the correct treatment is provided.

A novel method for predicting superior gluteal nerve safe zones in the lateral approach to the hip.

INTRODUCTION: The superior gluteal nerve (SGN) is at risk for laceration during lateral approach total hip arthroplasty (THA). The purpose of this study is to assess the accuracy of the trochanter-to-iliac crest distance (TCD) and the nerve-to-trochanter distance (NTD) ratio in determining a reproducible safe zone around the SGN independent of height. MATERIALS AND METHODS: Eighteen hemipelvises were dissected and the SGNs were exposed. The distance (NTD) from greater trochanter (GT) to the most inferior branch of the SGN encountered in each of the three approaches (Bauer et al., 1979) was measured. A reference distance (TCD) was measured from the GT to the highest point on the iliac crest. The NTD was divided by the TCD to generate standardized ratios. Coefficient of variation CV = (SD/mean) × 100 was calculated for each distance and ratio to measure relative variability. RESULTS: The standardized ratios (and CV) were determined for the nerve branches in three different surgical approaches: Hardinge 0.464 (0.9%), Bauer 0.406 (1.7%), and Frndak 0.338 (4.1%). There was a strong correlation of the individual NTDs with the TCD: NTD for Hardinge (r = 0.996, p < .001), NTD for Bauer (r = 0.984, p < .001), and NTD for Frndak (r = 0.932, p < .001). CONCLUSION: By measuring the TCD preoperatively and using the respective standardized ratios, surgeons can accurately predict the NTD and how proximal to the GT each SGN branch can be expected to be encountered during lateral approach to the hip. This will allow surgeons to work with a more precise safe zone around the SGN and minimize the possibility for a nerve injury.

Analysis of Host Responses to Hepatitis B and Delta Viral Infections in a Micro-scalable Hepatic Co-culture System.

Hepatitis B virus (HBV) remains a major global health problem with 257 million chronically infected individuals worldwide, of whom approximately 20 million are co-infected with hepatitis delta virus (HDV). Progress toward a better understanding of the complex interplay between these two viruses and the development of novel therapies have been hampered by the scarcity of suitable cell culture models that mimic the natural environment of the liver. Here, we established HBV and HBV/HDV co-infections and super-infections in self-assembling co-cultured primary human hepatocytes (SACC-PHHs) for up to 28 days in a 384-well format and highlight the suitability of this platform for high-throughput drug testing. We performed RNA sequencing at days 8 and 28 on SACC-PHHs, either HBV mono-infected or HBV/HDV co-infected. Our transcriptomic analysis demonstrates that hepatocytes in SACC-PHHs maintain a mature hepatic phenotype over time, regardless of infection condition. We confirm that HBV is a stealth virus, as it does not induce a strong innate immune response; rather, oxidative phosphorylation and extracellular matrix-receptor interactions are dysregulated to create an environment that promotes persistence. Notably, HDV co-infection also did not lead to statistically significant transcriptional changes across multiple donors and replicates. The lack of innate immune activation is not due to SACC-PHHs being impaired in their ability to induce interferon stimulated genes (ISGs). Rather, polyinosinic:polycytidylic acid exposure activates ISGs, and this stimulation significantly inhibits HBV infection, yet only minimally affects the ability of HDV to infect and persist. Conclusion: These data demonstrate that the SACC-PHH system is a versatile platform for studying HBV/HDV co-infections and holds promise for performing chemical library screens and improving our understanding of the host response to such infections.

Pullout Strength After Multiple Reinsertions in Radial Bone Fixation.

Background: Due to bone cutting loss from self-tapping screws (STS), progressive destruction of bone can occur with each reinsertion during surgery. When considering the use of jigs that utilize multiple insertions such as those seen in ulnar and radial shortening osteotomy systems, or scenarios where a screw needs to be removed and reinserted due to some technical issue, this can be concerning, as multiple studies examining the effects of multiple reinsertions and the relationship between insertional torque and pullout strength have had mixed results. Methods: Insertional torque and pullout strength were experimentally measured following multiple reinsertions of STS for up to 5 total insertions for various densities and locations along radial sawbone shafts. Results: Torque and pullout strength were significantly greater in middle segments of the radial shaft. Our trials corroborate previous literature regarding a significant reduction in fixation between 1 and 2 insertions; beyond this, there was no significant difference between pullout strength across all segment locations as well as bone densities for 3 to 5 insertions. There was a moderate to high correlation of insertional torque to pullout strength noted across all bone densities and segments (Pearson r = 0.663, P < .001). Conclusion: While reinsertion of STS between 1 and 2 insertions has been shown to significantly differ in pullout strength, beyond this, there does not appear to be a significant difference in up to 5 insertions at any specific region of radial bone across a range of sawbone densities. Further insertions may be considered with caution.

Superior Capsule Reconstruction With Subacromial Allograft Spacer: Biomechanical Cadaveric Study of Subacromial Contact Pressure and Superior Humeral Head Translation.

PURPOSE: To investigate the biomechanical effects of superior capsule reconstruction with subacromial allograft spacer on superior humeral head translation and subacromial contact pressure. METHODS: Eight cadaveric shoulder specimens were tested in 4 conditions: (1) intact rotator cuff, (2) supraspinatus tear and superior capsule excision, (3) superior capsule reconstruction with human dermal allograft, and (4) superior capsule reconstruction with subacromial resurfacing using human dermal allograft. In each condition, specimens were tested at 0, 30, 60, and 90° of shoulder abduction in balanced and unbalanced loaded states for subacromial contact pressure and superior humeral head translation. Statistical comparisons were made using a repeated-measures analysis of variance test, followed by a Tukey post hoc test for pairwise comparisons. A P value <.05 was set as statistically significant. RESULTS: Superior humeral head translation and subacromial contact pressure were increased after irreparable rotator cuff tear (P = .001). There was no significant difference between superior capsule reconstruction and intact cuff in regard to superior humeral head translation and subacromial contact pressure at all abduction angles. Superior capsule reconstruction with subacromial resurfacing decreased superior humeral head translation relative to intact (0°, P = .004; 30°, P = .02; 60°, P = .08; 90°, P = .01), superior capsule reconstruction (0°, P = .001; 30°, P = .003; 60°, P = .019; 90°, P = .001), and cuff-deficient states (P = .001). Superior capsule reconstruction with subacromial resurfacing resulted in nonsignificant increases in subacromial contact pressure relative to intact cuff at 0 to 90° abduction angles. CONCLUSIONS: Superior capsule reconstruction with subacromial resurfacing using human dermal allograft results in decreased superior humeral head translation relative to superior capsule reconstruction with human dermal allograft only, while increasing subacromial contact pressure. CLINICAL RELEVANCE: Superior capsule reconstruction with subacromial resurfacing using human dermal allograft reduces superior humeral head translation while increasing subacromial contact pressure in a cadaveric model.

In Hospital Outcomes of Total Hip Arthroplasty in the Medicaid Population.

Total hip arthroplasty (THA) is one of the most common orthopaedic procedures. This study's purpose was to evaluate national trends, patient demographics and hospital outcomes for Medicaid patients who underwent a primary THA. The National Hospital Discharge Survey (NHDS) database was queried for patients undergoing THA from 2001-2010. Patients were stratified into two groups based on insurance. We found from 2001-2005, Medicaid accounted for 2.38% of all THA performed, increasing insignificantly to 2.61% between 2006-2010. The Medicaid group was younger (50.3 vs. 65.6 years, p < 0.01). Length of stay was longer for the Medicaid group (4.6 vs. 4.0 days, p < 0.01). Medicaid patients were more likely to be discharged home (53.7% vs. 47.2%, p < 0.01) and less likely to be discharged to rehabilitation facilities (24.4% vs. 29.0%, p < 0.05). In conclusion, we discovered that the rate of Medicaid insurance in patients undergoing primary THA was stable through 2010, prior to the Affordable Care Act. We found Medicaid THA patients had longer length of stay, despite being a mean 15 years younger than the non-Medicaid cohort. Medicaid insurance status should be factored into risk adjustment models to avoid creating additional disincentive to treat the Medicaid population. (Journal of Surgical Orthopaedic Advances 28(4):281-284, 2019).

Osseous Rosai-Dorfman Disease Presenting as a Solitary Lesion of the Distal Radius.

Rosai-Dorfman disease, also known as sinus histiocytosis with massive lymphadenopathy, is a rare entity in which bone involvement occurs in less than 5% to 10% of patients and skeletal cases are usually multifocal. Extranodal solitary lesions of bone without nodal involvement or additional clinical manifestations are exceedingly rare. We present the clinical course and management of a 34-year-old African American woman who presented with the disease as a solitary lesion of the distal radius.

Allograft Tendon Interposition Arthroplasty of the Hallux Metatarsophalangeal Joint: A Technique Guide and Literature Review.

The "anchovy" interpositional arthroplasty technique can be used as a salvage option for failed hallux rigidus procedures. The operative technique utilized by the senior author is described. Careful soft-tissue handling, meticulous joint space and graft preparation, and interposition graft stabilization using a bone tunnel and suture anchors are unique aspects of this technique, which in the authors' experience have contributed to improved outcomes. Current literature regarding indications and outcomes is limited and controversial. The proposed benefits of soft-tissue interposition arthroplasty of the hallux metatarsophalangeal joint for patients with prior failed implant arthroplasty are improved pain scores and preservation of range of motion. Level of Evidence: Level V, technique guide.

Location of the Popliteal Artery in Knee Extension on Magnetic Resonance Imaging.

The goal of this study was to define the course of the popliteal artery (PA) and determine any variability among different patient demographics; by identifying risk factors for injury, surgeons can decrease patient morbidity and mortality. Ninety-four adult magnetic resonance imaging studies of the knee were reviewed. In extension, the artery is at most 7.87 mm posterior and 4.83 mm lateral to the midline below the tibial plateau. Proximally, the artery is more anterior and midline. With increasing body mass indexes, the artery is more posterior at any level. At the femur, 1 cm above the distal articular surface, the artery was more posterior in younger patients; 1 cm below the joint line, it was more posterior in elder patients. Attention should be given during total knee arthroplasty, revision surgery, lateral meniscal repair, posterior cruciate ligament reconstruction, high tibial osteotomy, and fixation of tibial tubercle fractures. Proximally, the PA is more anterior and midline, placing it at significant risk during these procedures. (Journal of Surgical Orthopaedic Advances 27(4):325-328, 2018).

Long-enduring primary hepatocyte-based co-cultures improve prediction of hepatotoxicity.

The failure of drug candidates during clinical trials and post-marketing withdrawal due to Drug Induced Liver Injury (DILI), results in significant late-stage attrition in the pharmaceutical industry. Animal studies have proven insufficient to definitively predict DILI in the clinic, therefore a variety of in vitro models are being tested in an effort to improve prediction of human hepatotoxicity. The model system described here consists of cryopreserved primary rat, dog or human hepatocytes co-cultured together with a fibroblast cell line, which aids in the hepatocytes' maintenance of more in vivo-like characteristics compared to traditional hepatic mono-cultures, including long term viability and retention of activity of cytochrome P450 isozymes. Cell viability was assessed by measurement of ATP following treatment with 29 compounds having known hepatotoxic liabilities. Hµrelrat™, Hµreldog™, and Hµrelhuman™ hepatic co-cultures were treated for 24h, or under repeat-dosing for 7 or 13days, and compared to rat and human hepatic mono-cultures following single-dose exposure for 24h. The results allowed for a comparison of cytotoxicity, species-specific responses and the effect of repeat compound exposure on the prediction of hepatotoxic potential in each model. Results show that the co-culture model had greater sensitivity compared to that of the hepatic mono-cultures. In addition, "time-based ratios" were determined by dividing the compounds' 24-hour TC50/Cmax values by TC50/Cmax values measured after dosing for either 7 or 13days. The results suggest that this approach may serve as a useful adjunct to traditional measurements of hepatotoxicity, improving the predictive value of early screening studies.

Long-term hepatitis B infection in a scalable hepatic co-culture system.

Hepatitis B virus causes chronic infections in 250 million people worldwide. Chronic hepatitis B virus carriers are at risk of developing fibrosis, cirrhosis, and hepatocellular carcinoma. A prophylactic vaccine exists and currently available antivirals can suppress but rarely cure chronic infections. The study of hepatitis B virus and development of curative antivirals are hampered by a scarcity of models that mimic infection in a physiologically relevant, cellular context. Here, we show that cell-culture and patient-derived hepatitis B virus can establish persistent infection for over 30 days in a self-assembling, primary hepatocyte co-culture system. Importantly, infection can be established without antiviral immune suppression, and susceptibility is not donor dependent. The platform is scalable to microwell formats, and we provide proof-of-concept for its use in testing entry inhibitors and antiviral compounds.The lack of models that mimic hepatitis B virus (HBV) infection in a physiologically relevant context has hampered drug development. Here, Winer et al. establish a self-assembling, primary hepatocyte co-culture system that can be infected with patient-derived HBV without further modifications.

Incidental Papillary Bladder Carcinoma on 18F-Fluoromethylcholine PET/CT Undertaken to Evaluate Prostate Malignancy.

FDG PET is known to have a low sensitivity for the detection of prostate and bladder tumors because of high levels of urinary excretion, which potentially obscures sites of disease. Fluoromethylcholine PET has a higher sensitivity for the detection of metastatic prostate cancer compared with F-FDG PET, partly because of lower levels of urinary excretion. We present a case of a patient who underwent F-fluoromethylcholine PET for possible recurrent prostate cancer. The study identified an incidental, avid metachronous bladder tumor. We discuss the potential use of fluoromethylcholine PET in the detection of bladder tumors.

Ventilation/perfusion single-photon emission computed tomography: a service evaluation.

OBJECTIVES: To identify the positive rate and negative predictive value (NPV) of our ventilation/perfusion (V/Q) single-photon emission computed tomography (SPECT) service as respective markers of overcalling (false positives) and undercalling (false negatives). We also identified the indeterminate rate as an indicator of the technical quality of the scans and reporter confidence. PATIENTS AND METHODS: V/Q SPECT studies carried out over 5 years were classified into positive, negative and indeterminate results. Patients who had died or had pulmonary emboli on imaging within 3 months of a negative V/Q SPECT were identified as false negatives, from which the NPV was calculated. The total number of positive and indeterminate studies as a proportion of all studies was calculated as the positive and indeterminate rates. RESULTS: The positive rate, NPV and indeterminate rates in nonpregnant patients were 24, 98.7-100 and 3.6%, respectively. The positive rate, NPV and indeterminate rates in pregnant patients were 6.8, 100 and 2.3%, respectively. CONCLUSION: The positive rate and NPV for nonpregnant patients were similar to the published literature. This suggests that we provide a safe service. The indeterminate rate was slightly higher than the stated guidelines. The study shows that the positive rate and NPV are achievable indicators of potential overcalling and undercalling in a V/Q SPECT service.This is also one of the first studies to report a positive rate in pregnant patients undergoing V/Q SPECT that other institutions can use as a standard when evaluating their services.

Long-term liver-specific functions of hepatocytes in electrospun chitosan nanofiber scaffolds coated with fibronectin.

In this study, a new 3D liver model was developed using biomimetic nanofiber scaffolds and co-culture system consisting of hepatocytes and fibroblasts for the maintenance of long-term liver functions. The chitosan nanofiber scaffolds were fabricated by the electrospinning technique. To enhance cellular adhesion and spreading, the surfaces of the chitosan scaffolds were coated with fibronectin (FN) by adsorption and evaluated for various cell types. Cellular phenotype, protein expression, and liver-specific functions were extensively characterized by immunofluorescent and histochemical stainings, albumin enzyme-linked immunosorbent assay and Cytochrome p450 detoxification assays, and scanning electron microscopy. The electrospun chitosan scaffolds exhibited a highly porous and randomly oriented nanofibrous structure. The FN coating on the surface of the chitosan nanofibers significantly enhanced cell attachment and spreading, as expected, as surface modification with this cell adhesion molecule on the chitosan surface is important for focal adhesion formation and integrin binding. Comparison of hepatocyte mono-cultures and co-cultures in 3D culture systems indicated that the hepatocytes in co-cultures formed colonies and maintained their morphologies and functions for prolonged periods of time. The 3D liver tissue model developed in this study will provide useful tools toward the development of engineered liver tissues for drug screening and tissue engineering applications. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 105A: 2119-2128, 2017.