One Health assessment of persistent organic chemicals and PFAS for consumption of restored anadromous fish.

BACKGROUND: Restoration efforts have led to the return of anadromous fish, potential source of food for the Penobscot Indian Nation, to the previously dammed Penobscot River, Maine. OBJECTIVE: U.S. Environmental Protection Agency (EPA), Penobscot Indian Nation's Department of Natural Resources (PINDNR), and Agency for Toxic Substances and Disease Registry (ATSDR), measured contaminants in six species of anadromous fish. Fish tissue concentrations were then used, along with exposure parameters, to evaluate potential human and aquatic-dependent wildlife risk. METHODS: PINDNR collected, filleted, froze, and shipped fish for analysis of polychlorinated biphenyls (PCBs), polybrominated diphenyl ethers (PBDEs), dioxins/furans, and per- and polyfluoroalkyl substances (PFAS). Contaminant levels were compared to reference doses (where possible) and wildlife values (WVs). RESULTS: Chemical concentrations ranged from 6.37 nanogram per gram (ng/g) wet weight (ww) in American Shad roe to 100 ng/g ww in Striped Bass for total PCBs; 0.851 ng/g ww in American Shad roe to 5.92 ng/g ww in large Rainbow Smelt for total PBDEs; and 0.037 ng/g ww in American Shad roe to 0.221 ng/g ww in Striped Bass for total dioxin/furans. PFAS concentrations ranged between 0.38 ng/g ww of PFBA in Alewife to 7.86 ng/g ww of PFUnA in Sea Lamprey. Dioxin/furans and PFOS levels indicated that there are potential human health risks. The WV for mink for total PCBs (72 ng/g) was exceeded in Striped Bass and the WV for Kestrel for PBDEs (8.7 ng/g) was exceeded in large Rainbow Smelt. Mammalian wildlife consuming Blueback Herring, Striped Bass, and Sea Lamprey may be at risk based on PFOS WVs from Canada. IMPACT: Anadromous fish returning to the Penobscot River potentially could represent the restoration of a major component of tribal traditional diet. However, information about contaminant levels in these fish is needed to guide the tribe about consumption safety. Analysis of select species of fish and risk calculations demonstrated the need for a protective approach to consumption for both humans and wildlife. This project demonstrates that wildlife can also be impacted by contamination of fish and their risks can be as great or greater than those of humans. A One Health approach addresses this discrepancy and will lead to a healthier ecosystem.

Prediction of in-hospital deterioration in normotensive pulmonary embolism remains elusive: external validation of the calgary acute pulmonary embolism score.

Acute pulmonary embolism (PE) is a frequently diagnosed condition. Prediction of in-hospital deterioration is challenging with current risk models. The Calgary Acute Pulmonary Embolism (CAPE) score was recently derived to predict in-hospital adverse PE outcomes but has not yet been externally validated. Retrospective cohort study of normotensive acute pulmonary embolism cases diagnosed in our emergency department between 2017 and 2019. An external validation of the CAPE score was performed in this population for prediction of in-hospital adverse outcomes and a secondary outcome of 30-day all-cause mortality. Performance of the simplified Pulmonary Embolism Severity Index (sPESI) and Bova score was also evaluated. 712 patients met inclusion and exclusion criteria, with 536 patients having a sPESI score of 1 or more. Among this population, the CAPE score had a weak discriminative power to predict in-hospital adverse outcomes, with a calculated c-statistic of 0.57. In this study population, an external validation study found weak discriminative power of the CAPE score to predict in-hospital adverse outcomes among normotensive PE patients. Further efforts are needed to define risk assessment models that can identify normotensive PE patients at risk for in hospital deterioration. Identification of such patients will better guide intensive care utilization and invasive procedural management of PE.

Adverse Clinical Outcomes Among Patients With Acute Low-risk Pulmonary Embolism and Concerning Computed Tomography Imaging Findings.

Importance: Most patients presenting to US emergency departments (EDs) with acute pulmonary embolism (PE) are hospitalized, despite evidence from multiple society-based guidelines recommending consideration of outpatient treatment for those with low risk stratification scores. One barrier to outpatient treatment may be clinician concern regarding findings on PE-protocol computed tomography (CTPE), which are perceived as high risk but not incorporated into commonly used risk stratification tools. Objective: To evaluate the association of concerning CTPE findings with outcomes and treatment of patients in the ED with acute, low-risk PE. Design, Setting, and Participants: This cohort study used a registry of all acute PEs diagnosed in the adult ED of an academic medical center from October 10, 2016, to December 31, 2019. Acute PE cases were divided into high- and low-risk groups based on PE Severity Index (PESI) class alone or using a combination of PESI class and biomarker results. The low-risk group was further divided based on the presence of concerning CTPE findings: (1) bilateral central embolus, (2) right ventricle-to-left ventricle ratio greater than 1.0, (3) right ventricle enlargement, (4) septal abnormality, or (5) pulmonary infarction. Data analysis was conducted from June to October 2022. Main Outcomes and measures: The primary outcome was all-cause mortality at 7 and 30 days. Secondary outcomes included hospitalization, length of stay, need for intensive care, use of echocardiography and/or bedside ultrasonography, and activation of the PE response team (PERT) . Results: Of 817 patients (median [IQR] age, 58 [47-71] years; 417 (51.0%) female patients; 129 [15.8%] Black and 645 [78.9%] White patients) with acute PEs, 331 (40.5%) were low risk and 486 (59.5%) were high risk by PESI score. Clinical outcomes were similar for all low-risk patients, with no 30-day deaths in the low-risk group with concerning CTPE findings (0 of 151 patients) vs 4 of 180 (2.2%) in the low-risk group without concerning CTPE findings and 88 (18.1%) in the high-risk group (P < .001). Low-risk patients with concerning CTPE findings were less frequently discharged from the ED than those without concerning CTPE findings (3 [2.0%] vs 14 [7.8%]; P = .01) and had more frequent echocardiography (87 [57.6%] vs 49 [27.2%]; P < .001) and PERT activation for consideration of advanced therapies (34 [22.5%] vs 11 [6.1%]; P < .001). Conclusions and Relevance: In this single-center study, CTPE findings widely believed to confer high risk were associated with increased hospitalization and resource utilization in patients with low-risk PE but not short-term adverse clinical outcomes.

Effect of pulmonary embolism response team on advanced therapies administered: The University of Michigan experience.

BACKGROUND: Pulmonary Embolism Response Teams (PERT) were employed at multiple institutions to bridge the gap between varied treatment options for acute PE and unclear evidence for optimal management. There is limited data regarding the impact of PERT on the use of advanced therapies and clinical outcomes. METHODS: We performed a retrospective single-center cohort study comparing patients that presented to the ED with an acute PE before and after the creation of PERT in June 2017 at our institution. We assessed utilization of advanced therapies, LOS, and mortality. RESULTS: A total of 817 patients (168 pre-PERT, 649 post-PERT) were evaluated in the ED with an acute PE between October 2016 and December 2019. Both groups were similar in demographics, comorbidities, and PESI score. There was a decrease in advanced therapy use (16 % vs. 7.5 %, p = 0.006) after PERT creation. Most notable decreases were in catheter-based therapies (8.5 % vs. 2.2 %, p = 0.008) and IVC filter placement (5.3 % vs. 3.2 %, p < 0.001). Median ICU LOS (2.5 days vs. 2.3 days, p = 0.55) and hospital LOS (3.1 vs. 3.0, p = 0.92) did not vary pre-PERT vs. post-PERT. In-hospital mortality (8.5 % vs. 5.0 %, p = 0.29) and 30-day all-cause mortality (1.2 % vs. 0.5 %, p = 0.28) were not different between the two groups as well. CONCLUSION: At our institution, PERT was associated with a decrease in advanced therapies administered to acute PE patients without affecting mortality or LOS. Additional studies to assess impact of this multi-disciplinary care team model on interventional therapies and clinical outcomes for PE at a broader level are necessary.

Heterotopic Ossification Prophylaxis in Acetabular Fracture Surgery: A Systematic Review.

Heterotopic ossification (HO) following acetabular fracture surgery is relatively common. The purpose of this study was to perform a systematic review of the literature regarding HO rates following acetabular surgery and the effectiveness of the various prophylactic measures taken to prevent its occurrence. A search of PubMed, MEDLINE, and Cochrane Database of Systematic Reviews was performed using the search terms ("Acetabular" OR "Acetabulum") AND ("Heterotopic Ossification" OR "HO" OR "Ectopic Ossification"). Inclusion criteria included articles published in English reporting on HO in acetabular fracture surgery. Descriptive statistics were calculated with categorical data presented as frequency with percentages and continuous data as means. Standard weighted means were calculated for all parameters. Sixty-six articles were included in this study with a total of 5,028 patients. HO was identified in 1,511 (30%) of fractures. Indomethacin (27%) and radiation therapy (24%) demonstrated decreased rates of HO formation versus no prophylaxis (36%). In particular, rates of severe HO formation were substantially decreased with radiation therapy (3%) and indomethacin (7%) compared to no prophylaxis (18%). Indomethacin and radiation therapy both appear to decrease HO formation and severity without substantially increasing surgical morbidity. (Journal of Surgical Orthopaedic Advances 32(4):217-224, 2023).

Free Vascularized Fibular Flap with Bilateral Bipolar Latissimus Transfer for Upper Extremity Reconstruction: A Case Report.

CASE: A 19-year-old woman presented with bilateral mangled upper extremities after jumping in front of a moving train. After revascularization, osteocutaneous free vascularized fibula flap was performed to reconstruct the right humerus. The left forearm required transradial amputation with acute targeted muscle reinnervation. Finally, staged bilateral bipolar latissimus dorsi functional muscle flaps were performed to restore elbow flexion. CONCLUSION: Staged orthoplastic reconstruction of the upper extremities is an effective treatment approach for traumatic bone and soft-tissue defects. This patient's recovery demonstrates improved quality of life after severe upper extremity trauma.

Risk factors for loss to follow up of pelvis and acetabular fractures.

INTRODUCTION: Pelvic and acetabular fracture incidence is increasing worldwide for more than four decades. There is currently no evidence examining risk factors for loss to follow up in patients with these injuries. METHODS: Patients presenting with pelvic and/or acetabular fractures at our institution between 2015 and 2020 were included. Demographic, injury, treatment, and follow up information was included. Excluded patients were those who sustained a pathologic fracture, has a course of treatment prior to transfer to our centre, or expired prior to discharge. RESULTS: 446 patients, 263 with a pelvic ring injury, 172 with an acetabular fracture, and 11 with combined injuries were identified. 271 (61%) of patients in our cohort followed up in Orthopaedic clinic (p = 0.016). With an odds ratio of 2.134, gunshot wound mechanism of injury was the largest risk factor for loss to follow up (p = 0.031) followed by male sex (OR= 1.859) and surgery with general trauma surgery (OR=1.841). The most protective risk factors for follow up with Orthopaedic surgery were operatively treated pelvic and acetabular fractures (OR=0.239) and Orthopaedic Surgery as the discharging service (OR=0.372). DISCUSSION: Numerous risk factors exist for loss to follow up including male sex, ballistic mechanism, and discharging service. Investigation into interventions to improve follow up in these patients are warranted.

Highly Cited Articles in Periacetabular Osteotomy Research.

Purpose: The aim of this study is to identify highly cited articles and examine trends and characteristics in research on periacetabular osteotomy. Materials and Methods: The 50 most highly cited articles on periacetabular osteotomy research were identified using Scopus. Data regarding article demographics and publication were collected from each article and an analysis was performed. Results: The mean citation count was 125±37. The article with the highest total citation count (796), five-year citation count (327), and five-year citation density (65/year) was reported by Reinhold Ganz. The five-year citation density showed strong correlation with total citation density (r=0.930, P<0.001). Reinhold Ganz, the most productive author, was listed on 13 articles in the cohort with 455 weighted citation points. Conclusion: This study provides a collection of articles examining periacetabular osteotomies and demonstrates that citation count can be regarded as an acceptable measure of the contemporary academic influence of an article.

Thymic Stromal Lymphopoietin Induction Suppresses Lung Cancer Development.

Lung cancer is the leading cause of cancer deaths in the United States and across the world. Immunotherapies, which activate tumor-infiltrating cytotoxic T lymphocytes, have demonstrated efficacy for the treatment of advanced-stage lung cancer. However, the potential for harnessing the immune system against the early stages of lung carcinogenesis to prevent cancer development and recurrence remains unexplored. Using a mouse model of lung adenocarcinoma, we investigated the effects of thymic stromal lymphopoietin (TSLP) induction on early cancer development in the lungs. Herein, we demonstrate that systemic TSLP induction suppressed spontaneous lung cancer development in KrasG12D mice. TSLP drove a significant CD4+ T cell response to block lung cancer progression from atypical alveolar hyperplasia to adenocarcinoma. Our findings suggest that TSLP can be used in the early stages of lung cancer development to trigger a lasting immunity in the tissue and prevent the development of advanced disease.

Algorithm Improves Acetabular Fracture Radiograph Interpretation Among Inexperienced Practitioners.

Acetabular fractures are often first evaluated in the emergency department, where physicians with little experience reading pelvic radiographs may be required to make an accurate diagnosis and early management decisions. In this study, medical students classified radiographs of 20 acetabular fractures and repeated the exercise three weeks later with the aid of a previously described algorithm; half the students were given a lesson prior to using the algorithm. The pre-algorithm accuracy was 4/20 and the post-algorithm accuracy was 8.3/20 (p<0.01). The lesson provided no difference (p=0.5). This algorithm is therefore a useful reference to help classify and triage acetabular fractures.

Review of Cancer-Specific Quality Measures Promoting the Avoidance of Low-Value Care.

BACKGROUND: With rising healthcare costs and campaigns aimed at avoiding low-value care, reducing cancer overtreatment has emerged as an important measure of cancer care quality. The extent to which avoidance of low-value care has been incorporated in cancer-specific quality measures is unknown. We aimed to identify and characterize cancer quality measures that promote the avoidance of low-value care, and identify gaps that may guide future measure development. METHODS: We systematically identified cancer-specific quality measures from leading quality measure organizations [e.g., National Quality Forum (NQF), National Quality Measures Clearinghouse (NQMC)]. We reviewed measures promoting the avoidance of low-value cancer care and subclassified them into disease site- or non-disease site-specific categories and the phase of care they targeted. RESULTS: We reviewed 313 quality measures from six organizations. Of these, 18% (n = 55) focused on avoidance of low-value care. Quality measures focused on end-of-life care were most likely to focus on low-value care [n = 13 (50%)], followed by breast [n = 12 (18%)], lung [n = 9 (31%)], colon [n = 8 (20%)], prostate [n = 5 (38%)], general cancer care [n = 4 (3%)], symptoms and toxicities [n = 2 (40%)], and palliative cancer care [n = 2 (11%)] measures. The phases of care quality measures targeted included low-value screening [n = 5 (9%)], diagnostic testing and staging [n = 7 (13%)], treatment [n = 19 (34%)], surveillance [n = 6 (11%)], and clinical outcomes [n = 18 (33%)]. All categories had a treatment-specific quality measure, but no category had a representative measure for every phase of care. DISCUSSION: A minority of cancer quality measures are aimed at avoiding low-value care, and multiple evidence-based recommendations targeting low-value care have not been incorporated.

Accuracy of Radiographic Displacement Measurement in a Pelvic Ring Injury Model.

BACKGROUND: Pelvic ring injury outcome studies rely on radiographic assessment. To date, no study investigates the accuracy of radiographic measurement. The aim of this study was to assess the accuracy and interobserver reliability of pelvic ring displacement measurement in an injury model. We hypothesize that current radiographic measurement methods do not accurately quantify the three-dimensional pelvic ring displacement. METHODS: Ten orthopaedic traumatologists evaluated 12 pelvic ring injury model displacements using AP, inlet, and outlet radiographs and axial CT images. Observers completed a survey of demographic and treatment approach strategies. Radiographic displacement measurements in axial, coronal, and sagittal planes were analyzed for accuracy using. Absolute displacement measurements were categorized with Matta and Tornetta grading system for Fleiss Kappa inter-reliability correlation evaluation. RESULTS: The mean age of orthopaedic traumatologists was 47.5 years (range 36 to 59) with a mean 15.3 years (range 4 to 27) of pelvic fracture surgery experience. Radiographic measurement of isolated uniplanar of pelvic displacement in axial, sagittal, or coronal plane alone was more accurate than multiplanar pelvic displacements with more than one plane of displacement, 6.6 ± 5.7 mm error compared with 9.6 ± 6.3 mm error, respectively (P = 0.0035). Measurement accuracy was greater with isolated coronal plane (4 ± 3.5 mm error) compared with isolated axial plane (9.9 ± 7.1 mm error) or isolated sagittal plane displacement (6.7 ± 4 mm error). Interrater reliability for the radiographic displacement measurement by observers showed an overall poor agreement with 0.24. CONCLUSION: Radiographic displacement measurement in these modeled pelvic ring injuries has notable inaccuracy among various measurement methods. Coronal and sagittal plane radiographic displacement measurements are more accurate compared with axial plane measurement. The reporting of radiographic displacement measurement outcomes in clinical research studies should be critically evaluated, and standardization of pelvic ring injury displacement may not be achievable with radiography. LEVEL OF EVIDENCE: Level V.

Clinician Attitudes and Beliefs About Deintensifying Head and Neck Cancer Surveillance.

Importance: Surveillance imaging and visits are costly and have not been shown to improve oncologic outcomes for patients with head and neck cancer (HNC). However, the benefit of surveillance visits may extend beyond recurrence detection. To better understand surveillance and potentially develop protocols to tailor current surveillance paradigms, it is important to elicit the perspectives of the clinicians who care for patients with HNC. Objective: To characterize current surveillance practices and explore clinician attitudes and beliefs on deintensifying surveillance for patients with HNC. Design, Setting, and Participants: This qualitative study was performed from January to March 2021. Guided by an interpretive description approach, interviews were analyzed to produce a thematic description. Data analysis was performed from March to April 2021. Otolaryngologists and radiation oncologists were recruited using purposive and snowball sampling strategies. Main Outcomes and Measures: The main outcomes were current practice, attitudes, and beliefs about deintensifying surveillance and survivorship as well as patients' values and perspectives collected from interviews of participating physicians. Results: Twenty-one physicians (17 [81%] men) were interviewed, including 13 otolaryngologists and 8 radiation oncologists with a median of 8 years (IQR, 5-20 years) in practice. Twelve participants (57%) stated their practice comprised more than 75% of patients with HNC. Participants expressed that there was substantial variation in the interpretation of the surveillance guidelines. Participants were open to the potential for deintensification of surveillance or incorporating symptom-based surveillance protocols but had concerns that deintensification may increase patient anxiety and shift some of the burden of recurrence monitoring to patients. Patient and physician peace of mind, the importance of maintaining the patient-physician relationship, and the need for adequate survivorship and management of treatment-associated toxic effects were reported to be important barriers to deintensifying surveillance. Conclusions and Relevance: In this qualitative study, clinicians revealed a willingness to consider altering cancer surveillance but expressed a need to maintain patient and clinician peace of mind, maintain the patient-clinician relationship, and ensure adequate monitoring of treatment-associated toxic effects and other survivorship concerns. These findings may be useful in future research on the management of posttreatment surveillance.

Risks from mercury in anadromous fish collected from Penobscot River, Maine.

Levels of total mercury were measured in tissue of six species of migratory fish (alewife, American shad, blueback herring, rainbow smelt, striped bass, and sea lamprey), and in roe of American shad for two consecutive years collected from the Penobscot River or its estuary. The resultant mercury levels were compared to reference doses as established in the U.S. Environmental Protection Agency (EPA) Integrated Risk Information System and wildlife values. Mercury concentrations ranged from 4 µg/kg ww in roe to 1040 µg/kg ww in sea lamprey. Sea lamprey contained the highest amounts of mercury for both seasons of sampling. Current health advisories are set at sufficient levels to protect fishers from harmful consumption of the fish for mercury alone, except for sea lamprey. Based upon published wildlife values for mink, otter, and eagle, consumption of rainbow smelt, striped bass, or sea lamprey poses a risk to mink; striped bass and sea lamprey to otter; and sea lamprey to eagle. For future consideration, the resultant data may serve as a reference point for both human health and wildlife risk assessments for the consumption of anadromous fish. U.S. EPA works with federally recognized Tribes across the nation greatly impacted by restrictions on sustenance fishing, to develop culturally sensitive risk assessments.

The Quadrilateral Plate in Acetabular Fracture Surgery: What Is It and When Should It Be Addressed?

The quadrilateral plate (QP) is the relatively flat surface of bone in the true pelvis lying directly medial to the acetabulum. This surface is frequently involved in acetabular fractures. Elderly individuals, in particular, commonly sustain anterior column fractures with incomplete or complete posterior hemitransverse fracture lines with associated QP comminution. If QP fracture lines propagate through the superior weight-bearing surface of the acetabulum, the femoral head may displace medially, leading to poor outcomes if not addressed. Fortunately, the collective work of many orthopaedic surgeons has resulted in numerous effective methods for approaching, reducing, and stabilizing the QP and the diverse family of fractures which affect it. A thorough understanding of the QP, its anatomy, radiology, and techniques for fixation, is required to optimize patient outcomes.

Patient-Reported Outcomes Measurement Information System Correlates With Modified Harris Hip Score in Total Hip Arthroplasty.

The modified Harris Hip Score (mHHS) is a validated and disease-specific instrument commonly used to assess outcomes in total hip arthroplasty (THA). The Patient-Reported Outcomes Measurement Information System (PROMIS) is a validated, computer adaptive testing (CAT)-based global health assessment tool. The authors' goal was to examine the correlation between PROMIS Pain Interference and Physical Function CATs and the mHHS in patients undergoing primary THA. All THAs were performed by 1 of 2 fellowship-trained dedicated total joint surgeons at 1 academic institution. Patients completed PROMIS and mHHS assessments preoperatively and at 3, 6, 12, and 52 weeks postoperatively. Descriptive statistics and Pearson correlation values were determined. A total of 48 patients were prospectively enrolled in the study. Preoperatively, mean total PROMIS score (Pain Interference and Physical Function) was 74.2 and mHHS was 50.8. Preoperatively, mean total PROMIS score showed a moderate correlation (r=0.56; P<.0001) with total mHHS. Postoperatively, mean total PROMIS score at 3, 6, 12, and 52 weeks was 82.4, 93.4, 100, and 100, respectively (all P<.01 vs baseline), and mHHS was 68.2, 81.1, 85.9, and 88.6, respectively (all P<.01). At 3, 6, 12, and 52 weeks postoperatively, a strong and consistent correlation was observed between the total PROMIS score and mHHS (r=0.74, 0.74, 0.73, and 0.80, respectively; all P<.0001). The PROMIS Pain Interference and Physical Function CATs accurately assessed preoperative pain and dysfunction, as well as clinical improvement following THA. Combined PROMIS Pain Interference and Physical Function is comparable to the mHHS when assessing outcome following THA for osteoarthritis. [Orthopedics. 2021;44(1):e19-e25.].

Assessment of Psychological Factors in Short-Stay Total Hip Arthroplasty Protocol.

BACKGROUND: Several variables are known to correlate with the successful completion of short-stay total hip arthroplasty (THA) protocols. The role of psychological factors remains unclear. We investigated the interaction between patient-reported measures of psychological fitness and successful completion of a short-stay THA protocol. METHODS: We performed a prospective cohort study of patients undergoing elective anterior total hip arthroplasty enrolled in a short-stay protocol (success defined as LOS ≤1 midnight versus failed, LOS >1 midnight). Psychological fitness was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) domains for self-efficacy, depression, anxiety, emotional support, and the ability to participate in social roles. PROMIS scores, patient demographics, and surgical factors were assessed for a relationship with failure to complete short-stay protocol. RESULTS: Patients that failed to complete the short-stay protocol had higher mean pre-operative PROMIS depression scores (50.8 vs 47.1, P = .025) and anxiety scores (53.6 vs 49.2, P = .008) and higher postoperative PROMIS depression (48.19 vs 43.49, P = .003) and anxiety scores (51.7 vs 47.1, P = .01). Demographic and surgical variables did not correlate with the successful completion of the short-stay protocol. That seventy-six percent of the patients did not adhere to the short-stay protocol was due to the inability to complete a physical therapy standardized safety assessment. CONCLUSION: Higher levels of preoperative and postoperative anxiety and depression in otherwise psychologically healthy patients, is associated with an increased risk of failure to complete a short-stay protocol following THA. Targeted interventions are needed to facilitate rapid recovery in patients with psychological barriers to early mobilization.

Assessment of Hip Translation In Vivo in Patients With Femoracetabular Impingement Syndrome Using 3-Dimensional Computed Tomography.

PURPOSE: To determine the 3-dimensional (3D) in vivo hip translation in patients with symptomatic femoroacetabular impingement syndrome (FAIS) using 3D computed tomography (CT) models with the hip in neutral and FABER (flexion, abduction, and the external rotation) positions and to identify patient predictors associated with the degree of hip translation. METHODS: Seventy-eight patients with FAIS and cam lesions underwent CT scans in neutral and FABER positions. Demographics including age, sex, and body mass index (BMI) were recorded for each patient. The cam deformity was characterized both in plain x-ray film and 3D. Translation between both positions was calculated using a validated high-precision 3D-3D registration technique. Univariate and multivariate regression analyses sought factors correlated with translation. RESULTS: The mean age of the patients included in the analysis was 36.3 ± 9.2 years, with 51% of the study group being female. The mean 3D femoral head center translation was 0.84 ± 0.37 mm, decomposed into vectors on standard anatomical directions as 0.13 ± 0.58 mm medial, 0.10 ± 0.54 mm posterior, and 0.08 ± 0.46 mm inferior. Multivariate analysis demonstrated that total translation was associated with larger alpha angles (ß = 0.014; 95% confidence interval [CI] 0.003-0.024; P = .013), and greater BMI (ß = 0.033; 95% CI 0.001-0.065; P = .042). Furthermore, posterior-inferior translation was associated with BMI (ß = 0.032; 95% CI 0.003-0.061; P = .031), whereas medial-lateral translation is associated with the female sex (ß = 0.388; 95% CI 0.124-0.634; P = .002), and smaller head radius (ß = -0.068; 95% CI -0.128 to -0.007; P = .029). CONCLUSIONS: As a provocative maneuver, FABER positioning in patients with FAIS resulted in an average measurable translation of the femoral head center in the posterior, medial, and inferior direction. Factors including sex, BMI, and alpha angle predicted the degree of translation. CLINICAL RELEVANCE: The current study demonstrates that there is measurable hip translation between the neutral and FABER positions in patients with symptomatic FAIS, which may cause hip microinstability. Furthermore, the study found an association between hip translation and both modifiable and nonmodifiable factors. This may indicate the need for more comprehensive preoperative surgical planning, intraoperative dynamic examination of the hip, and consideration of capsular plication in certain patients.

Minimally Invasive Medial Plate Osteosynthesis of High-Energy Pediatric Tibia Fractures.

OBJECTIVES: We report on the largest series to date of minimally invasive medial plate osteosynthesis of high-energy tibia fractures in skeletally immature patients. DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS: Skeletally immature patients with high-energy tibia fractures treated with minimally invasive medial plate osteosynthesis between 2006 and 2017. We identified 28 fractures in 26 patients. MAIN OUTCOME MEASURE: We reviewed the record for patient, injury, and treatment factors as well as for complications and reoperation. We assessed the relationships between age, implant selection, and implant removal using χ and t test analyses. RESULTS: Mean age was 12 years (4-15) with OTA/AO classifications including 42A (18), 42B (6), and 42C (4). There were 10 open fractures (1 type I, 2 type II, and 7 type III). Mean follow-up was 37.6 months (minimum 7). Mean time to full weight-bearing and union was 2 and 3 months, respectively. Plate stock (2.7, 3.5, and 4.5 mm) and length (6-20 holes) varied independent of age, P = 0.19. There were 2 superficial infections, one 15 mm leg length discrepancy, and one case of fasciotomy at the time of plate fixation for trauma-related compartment syndrome. Implant removal was more likely in younger patients (10.9 vs. 13.2 years, P = 0.04) and not associated with plate stock, P = 0.97. There were no neurovascular injuries, losses of reduction, or rotational deformities. Angulation was universally <5 degrees in the coronal plane and <10 degrees in the sagittal plane. CONCLUSIONS: Minimally invasive medial plate osteosynthesis of high-energy pediatric tibia fractures may be performed with a low rate of complications and should be considered in this select patient population with multiple injuries, high-energy mechanisms, and significant soft-tissue trauma. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes following extra-articular fractures of the scapula: A systematic review.

BACKGROUND: Scapular neck and body fractures are typically treated nonoperatively, with operative treatment traditionally focused on intraarticular fractures or double disruptions of the shoulder suspensory complex. The objective of this study was to systematically examine and compile the existing literature in regard to operative and conservative treatment of extraarticular fractures of the scapula. METHODS: A comprehensive search of multiple electronic databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to find outcome data on fractures of the scapular neck and body. All studies from 1988 to 2018 that met inclusion criteria were reviewed independently and graded based on the modified Coleman Methodology Score. Outcomes of interest were compiled and analyzed for adjusted means. RESULTS: 42 manuscripts with a total of 669 patients were included for analysis from an initial search of 335 results. There was an average age of 41.2 years, 78.1% were male, 98.8% had a blunt force mechanism, and 66.7% had other injures outside the scapula at time of presentation. In total, there were 120 patients with scapular body fractures, 95 with scapular neck fractures, 130 with floating shoulder injuries including a scapular neck or body fracture, and 324 with an unspecified extraarticular scapular fracture. 464 patients were treated operatively, with a mean union rate of 99.4%, Constant score of 84.4, and end forward elevation of 158°. 205 total patients were treated non-operatively, with a mean union rate of 85.1%, Constant score of 79.0, and end forward elevation of 153°. CONCLUSION: Patients with extraarticular fractures of the scapula have excellent outcomes following either nonoperative or operative management. There is a need for high quality comparative studies to determine the optimal treatment strategy for these injuries.