Current Trends in the Surgical Treatment of Fibular Fractures: A National Database Study of Intramedullary vs. Plate Fixation Practice Patterns, Complications, and Cost.

Existing primary evidence comparing fibular intramedullary fixation (IMF) with traditional plate fixation (PF) for the treatment of distal fibular fractures remains limited by modest sample sizes. Using a large national database, this study aims to compare use rates, fracture patterns, patient characteristics, time to surgery, complication rates, and cost between fibular IMF and PF within the United States. Adults treated with fibular IMF or PF between October 2015 and October 2021 were identified within the PearlDiver Database. The ratio of IMF-treated to PF-treated patients was tracked temporally to compare use rates. Fracture patterns were determined using fracture diagnoses within one-month preceding surgery. Further comparisons of IMF- and PF-treated groups only included patients with at least 12 months of follow-up, and patients with upper tibia or tibia shaft fractures were excluded. An analysis of cohorts matched at a 1 : 4 (IMF: PF) ratio to control for risk factors was performed to compare time to surgery, complication rates (infection, nonunion, malunion, revision, hardware removal, pulmonary embolism, and deep vein thrombosis), and cost. 39329 patients (2294 IMF and 37035 PF) were identified. IMF use trended upwards relative to PF use over time. Tibia and fibula shaft fractures were the most common injuries in IMF patients versus bimalleolar and trimalleolar fractures in PF patients. A higher proportion of IMF patients had open fractures. IMF patients were younger, with higher mean ECI, fewer female patients, and higher rates of CKD. Percutaneous approaches were more common among IMF patients. There were no significant differences in time to surgery or complication rates. IMF was less costly. The popularity of IMF trended upwards across the study period. IMF was used more commonly in injuries involving higher energy trauma and soft tissue disruption. Overall, IMF patients were younger with more comorbidities. When used in similar populations, IMF appears to be a cost-effective alternative to PF.

Current Procedural Terminology Code Selection, Attitudes, and Practices of the Orthopaedic Surgery Resident Case Log: A Survey of Residents and Program Directors.

Introduction: The Accreditation Council for Graduate Medical Education Resident Case Log is one of the primary tools used to track surgical experience. Owing to the self-reported nature of case logging, there is uncertainty in the consistency and accuracy of case logging. The aims of this study are two-fold: to assess current resident case log Current Procedural Terminology (CPT) code selection and practices across orthopaedic surgery residencies and to understand current attitudes of both program directors (PD) and residents surrounding case logging. Methods: Residents and PDs from 18 residency programs received standardized, consensus-built surveys distributed through the Collaborative Orthopaedic Educational Research Group. Resident surveys additionally contained clinical orthopaedic subspecialties vignettes on sports, trauma, and spine. Each subspecialty section contained 4 clinical vignettes with stepwise increases in complexity/CPT coding procedures. Results: One hundred sixteen residents (response rate: 28.4%) and 16 PDs (response rate: 88.9%) participated. Formal case log training was reported by 53.0% of residents and 56.3% of PDs. A total of 7.8% of residents rated themselves "excellent" at applying CPT codes for the case log, while 0.0% PDs rated their residents' ability as "excellent." In total, 40.9% of residents and 81.3% of PDs responded that it was "extremely important" or "very important" to code accurately (p = 0.006). Agreement between resident CPT code selection and number of cases and procedures logged for each clinical vignette was conducted using Fleiss' kappa. As the clinical vignettes increased in complexity, there was a decreasing trend in kappa values from the first (least complex) to the last (most complex) clinical vignette. Conclusions: The inconsistent case logging practices, dubious outlook on case log accuracy and resident case logging ability and attitude, and lack of formal training signals a need for formal, standardized case log training. Enhanced case logging instruction and formalized educational training for PDs and residents would be a meaningful step toward capturing true operative experience, which would have a substantial impact on orthopaedic surgery resident education and assessment.

The ballistic articular structure injury classification (BASIC) system: clarifying ballistic articular injuries.

PURPOSE: This study aims to (1) devise a classification system to categorize and manage ballistic fractures of the knee, hip, and shoulder; (2) assess the reliability of this classification compared to current classification schemas; and (3) determine the association of this classification with surgical management. METHODS: We performed a retrospective review of a prospectively collected trauma database at an urban level 1 trauma centre. The study included 147 patients with 169 articular fractures caused by ballistic trauma to the knee, hip, and shoulder. Injuries were selected based on radiographic criteria from plain radiographs and CT scans. The AO/OTA classification system's reliability was compared to that of the novel ballistic articular injury classification system (BASIC), developed using a nominal group approach. The BASIC system's ability to guide surgical decision-making, aiming to achieve stable fixation and minimize post-traumatic arthritis, was also evaluated. RESULTS: The BASIC system was created after analysing 73 knee, 62 hip, and 34 shoulder fractures. CT scans were used in 88% of cases, with 44% of patients receiving surgery. The BASIC classification comprises five subgroups, with a plus sign indicating the need for soft tissue intervention. Interrater reliability showed fair agreement for AO/OTA (k = 0.373) and moderate agreement for BASIC (k = 0.444). The BASIC system correlated strongly with surgical decisions, with an 83% concurrence in treatment choices based on chart reviews. CONCLUSIONS: Conventional classification systems provide limited guidance for ballistic articular injuries. The BASIC system offers a pragmatic and reproducible alternative, with potential to inform treatment decisions for knee, hip, and shoulder ballistic injuries. Further research is needed to validate this system and its correlation with patient outcomes. LEVEL OF EVIDENCE: Level III, Diagnostic Study.

A Retrospective Study of Ballistic Pelvic Fractures with Focus on Short-Term Clinical Outcomes.

OBJECTIVES: To evaluate the orthopaedic management, associated injuries, and outcomes in patients treated for low-velocity ballistic pelvic fractures. METHODS: Design: Retrospective chart review. SETTING: Single urban Level I Trauma Center. PATIENT SELECTION CRITERIA: Patients aged 15 years or older treated for low-velocity ballistic pelvic (OTA/AO 61 and 62) fractures from May 2018 to August 2021. OUTCOME MEASURES AND COMPARISONS: Primary study measures included pelvic fracture location, concomitant associated injuries, surgical interventions, and antibiotic treatment. Post-injury sequelae evaluated include infection, neurologic deficit, and need for orthopaedic removal of foreign body. Risk factors for post-injury sequelae were investigated. RESULTS: A total of 156 patients with ballistic pelvic fractures were included. The cohort consisted of 135 (86.5%) males and a mean age of 29.8 years. One hundred and ten (70.5%) patients sustained two or more GSWs. Ninety-eight (62.8%) patients underwent an exploratory laparotomy with 79 (50.6%) having a confirmed concomitant intestinal injury. Additional associated injuries included nerve injury (13.5%), vascular injury requiring repair or embolization (10.9%), and bladder injury (10.3%). Nine (5.7%) patients underwent orthopaedic operative management - five (3.2%) patients for operative fixation and four (2.5%) patients for removal intra-articular foreign bodies. Diabetes (OR: 33.1, p=0.025), neurologic deficit on presentation (OR: 525.2, p<0.001), vascular injury requiring repair or embolization (OR 8.7, p=0.033), and orthopaedic pelvic fixation (OR: 163.5, p=0.004) were positively associated with the defined post-injury sequelae at 30 and 90 days of follow-up. There was not a statistically significant association between infection and retained foreign body (OR: 3.95 [95% CI 0.3 - 58.7, p = 0.318]) or bowel contamination (OR: 6.91 [95% CI 0.4 - 58.7, p = 0.178]). CONCLUSIONS: Ballistic fractures of the pelvis and acetabulum rarely underwent operative fixation (3.2%) or irrigation and debridement. Neither retained foreign body nor presumed bowel contamination of pelvic fractures had a statistically significant association with infection which further supports conservative management of these injuries. Patients with diabetes, neurologic deficit on presentation, vascular injury necessitating intervention, and orthopaedic fixation of pelvic fracture are associated with increased risk of post-injury sequelae. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Gunshot Trauma Patients Have Higher Risk of PTSD Compared With Blunt Trauma and Elective Populations: A Retrospective Comparative Study of Outpatient Orthopaedic Care.

BACKGROUND: Posttraumatic stress disorder (PTSD) has been extensively studied in patients who have experienced natural disasters or military conflict, but there remains a substantial gap in knowledge about the prevalence of PTSD after civilian orthopaedic trauma, especially as related to firearms. Gun violence is endemic in the United States, especially in urban centers, and the mental impact is often minimized during the treatment of physical injuries. QUESTIONS/PURPOSES: (1) Do patients who experience gunshot wound (GSW) trauma have higher PTSD screening scores compared with patients with blunt or other trauma (for example, motor vehicle and motorcycle accidents or stab wounds) and those with elective conditions (for example, arthritis, tendinitis, or nerve compression)? (2) Are PTSD scores correlated with pain scores in patients with GSW trauma, those with non-GSW trauma, and patients with elective orthopaedic symptoms? METHODS: We performed a retrospective study of adults older than 18 years of age presenting to an orthopaedic clinic over an 8-month period between August 2021 and May 2022. All patients presenting to the clinic were approached for inclusion (2034 patients), and 630 new or postoperative patients answered study surveys as part of routine care. Patients were divided into three cohorts based on the orthopaedic condition with which they presented, whether gunshot trauma, blunt trauma, or elective orthopaedic symptoms. Overall, the results from 415 patients were analyzed, including 212 patients with elective orthopaedic symptoms, 157 patients with non-GSW trauma, and 46 patients with GSW trauma. Clinical data including demographic information were collected at the time of appointment and abstracted along with results from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, short screening questionnaire, which uses a 7-item scale scored from 0 to 7 (with higher scores representing worse symptoms), and from the numeric rating scale for pain (range 0 to 10). Both questionnaires were routinely administered by medical assistants at patient intake. The proportions of patients completing PTSD scoring were 45% (95) in the elective group, 74% (116) in the group with non-GSW trauma, and 85% (39) in the group with GSW trauma (p = 0.01). We compared the PTSD scores across the three groups and then dichotomized the scores as a negative versus positive screening result at a value of ≥ 4 with further comparative analysis. The correlation between pain and PTSD scores was also evaluated. RESULTS: Patients with GSW trauma had higher mean ± SD PTSD scores compared with those who had non-GSW trauma (4.87 ± 4.05 versus 1.75 ± 2.72, mean difference 3.21 [95% CI 1.99 to 4.26]; p < 0.001) and those who presented with elective conditions (4.87 ± 4.05 versus 0.49 ± 1.04, mean difference 4.38 [95% CI 3.50 to 5.26]; p < 0.001). When dichotomized for positive or negative PTSD screening results, patients with GSW trauma had a higher risk of having PTSD (64% [25 of 39]) compared with patients with non-GSW trauma (27% [31 of 116], relative risk 2.40 [95% CI 1.64 to 3.51]; p < 0.001) and compared with patients with elective conditions (4% [4 of 95], relative risk 15.22 [95% CI 5.67 to 40.87]; p < 0.001). Pain scores were correlated with PTSD scores only for patients with non-GSW trauma (ρ = 0.37; p < 0.0001). No correlation with pain scores was present for patients with GSW (ρ = 0.24; p = 0.16) or patients with elective conditions (ρ = -0.04; p = 0.75). CONCLUSION: In an orthopaedic clinic population, the prevalence of positive screening for PTSD was highest in the population sustaining gunshot trauma as compared with blunt or other trauma and elective orthopaedic conditions. Interestingly, pain scores correlated with PTSD screening only in the patients with non-GSW trauma. These differences suggest a substantial difference in the populations at risk of PTSD after trauma. Overall, the psychological impacts of gun trauma are poorly understood. The next step would be to prospectively study the differences and timelines of PTSD screening in patients with GSW trauma in comparison with patients with blunt or other trauma to better define the treatment needs in this population. LEVEL OF EVIDENCE: Level III, prognostic study.

Normothermia to Decrease Surgical Site Infection Risk: Silver Bullet or Fool's Gold? A Retrospective Cohort Study.

PURPOSE: Surgical site infection (SSI) is the leading cause of nosocomial infections among surgical patients in the United States. Currently, there is compelling evidence suggesting that temperature dysregulation in surgical patients may be a risk factor for the development of SSI. We examined the relationship between perioperative hypothermia (PH) and SSI in a population of surgical patients with diabetes mellitus (DM). METHODS: This retrospective cohort review was conducted on patients with a history of DM undergoing orthopaedic surgery at our institution between May 1, 2018, and April 1, 2022. Inclusion criteria were age older than 15 years, a history of DM or recent hemoglobin A1c concentration of ≥6.5%, and operation of at least 60 minutes under general anesthesia. Perioperative hypothermia was defined as an intraoperative temperature ≤ 35.5°C. Continuous variables were compared using the t-test and Wilcoxon rank-sum test. Categorical variables were compared using the chi-squared test. We constructed a multivariable logistic regression model to estimate SSI risk while controlling for demographic variables. RESULTS: A total of 236 patients were included in the final analysis. The overall incidence of SSI was 5.93%. 99 patients (42%) experienced PH. No difference was observed in the risk of SSI between the normothermic and hypothermic cohorts. Among the 99 patients who experienced PH, increasing HbA1c was associated with increasing risk of SSI (OR = 2.39, 95% CI = 1.12 to 5.32, P-value = 0.0222). The multivariable logistic regression model had good discriminatory ability (c-statistic 0.74, 95% CI: 0.61 to 0.89) and good predictive accuracy (sensitivity 64%, specificity 73%). DISCUSSION: PH is not an independent risk factor of SSI. However, in the presence of elevated HbA1c, PH may more than double the risk of SSI. Perioperative hypothermia may be an additive risk factor in the setting of poor glycemic control and potentially in the setting of other known risk factors.

Do preoperative glucose levels predict risk of complications in orthopaedic surgery?

PURPOSE: Post-operative hyperglycemia is a known risk factor for post-surgical complications. The predictive value of pre-operative blood glucose levels, however, is less understood. This study aimed to determine if pre-operative screening blood glucose levels affect the rate of post-operative infection or wound complications. We also investigated if case urgency or anatomic location alters this relationship. METHODS: A single-institution retrospective chart review was performed to evaluate patients treated between 2018 and 2021. Subjects ≥ 18 years with closed, non-infected orthopaedic diagnoses requiring surgery were included. Case urgency, demographics, comorbidities, blood glucose level within twelve h prior to surgery, and hemoglobin A1c level within 3 months of surgery, were collected. Infections and wound complications were recorded as outcomes. RESULTS: A total of 775 subjects with a mean age of 61 (range 18-96) were identified, including 543 elective and 232 trauma patients, with a mean pre-operative fasting glucose value of 127.7 mg/dL (range, 49-388 mg/dL) and average HbA1c of 6.9%. The odds of infectious complications were increased by a factor of 1.01 for every 1-point increase in blood glucose (95% CI 1.01-1.02; p < 0.01). CONCLUSIONS: Pre-operative blood glucose levels greater than 137 mg/dL were associated with an increase in wound complications, but not deep infections. Infection rates stratified by anatomic site and case urgency were not impacted by pre-operative glucose levels. The increased risk of poor wound healing in patients with pre-operative hyperglycemia demonstrates that day of surgery point-of-care blood glucose screening can be a useful risk stratification tool.

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.

Lactic acid levels are associated with morbidity, length of stay, and total treatment costs in urban trauma patients with lower extremity long bone fractures.

INTRODUCTION: Lactic acid is well studied in the trauma population and is frequently used as a laboratory indicator that correlates with resuscitation status and has thus been associated with patient outcomes. There is limited literature that assesses the association of initial lactic acid with post-operative morbidity and hospitalization costs in the orthopedic literature. The purpose of this study was to assess the association of lactic acid levels and alcohol levels post-operative morbidity, length of stay and admission costs in a cohort of operative lower extremity long bone fractures, and to compare these effects in the ballistic and blunt trauma sub-population. METHODS: Patients presenting as trauma activations who underwent tibial and/or femoral fixation at a single institution from May 2018 to August 2020 were divided based on initial lactate level into normal, (< 2.5) intermediate (2.5-4.0), and high (> 4.0). Mechanism of trauma (blunt vs. ballistic) was also stratified for analysis. Data on other injuries, surgical timing, level of care, direct hospitalization costs, length of stay, and discharge disposition were collected from the electronic medical record. The primary outcome assessed was post-operative morbidity defined as in-hospital mortality or unanticipated escalation of care. Secondary outcomes included hospital costs, lengths of stay, and discharge disposition. Data were analyzed using ANOVA and multivariate regression. RESULTS: A total of 401 patients met inclusions criteria. Average age was 34.1 ± 13.0 years old, with patients remaining hospitalized for 8.8 ± 9.5 days, and 35.2% requiring ICU care during their hospitalization. Patients in the ballistic cohort were younger, had fewer other injuries and had higher lactate levels (4.0 ± 2.4) than in the blunt trauma cohort (3.4 ± 1.9) (p = 0.004). On multivariate regression, higher lactate was associated with post-operative morbidity (p = 0.015), as was age (p < 0.001) and BMI (p = 0.033). ISS, ballistic versus blunt injury mechanism, and other included laboratory markers were not. Lactate was also associated with longer lengths of stay, and higher associated direct hospitalization cost (p < 0.001) and lower rates of home disposition (p = 0.008). CONCLUSION: High initial lactate levels are independently associated with post-operative morbidity as well as higher direct hospitalization costs and longer lengths of stay in orthopedic trauma patients who underwent fixation for fractures of the lower extremity long bones. Ballistic trauma patients had significantly higher lactate levels compared to the blunt cohort, and lactate was not independently associated with increased rates of post-operative morbidity in the ballistic cohort alone. LEVEL OF EVIDENCE: 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.

AOA Critical Issues Symposium: Gun Violence as a Public Health Crisis.

ABSTRACT: Gun violence is an epidemic throughout the United States and is increasing around the world-it is a public health crisis. The impact of gun violence is not limited to the victims (our patients); it also extends to the physicians and caregivers who are taking care of these patients every day. Even more broadly, gun violence affects those living and going to work in potentially dangerous environments. The "vicarious trauma" that is experienced in these situations can have long-term effects on physicians, nurses, and communities. Importantly, socioeconomic disparities and community deprivation strongly correlate with gun violence. Systemic factors that are deeply ingrained in our society can increase concerns for these underrepresented patient populations and cause increased stressors with substantial health consequences, including delayed fracture-healing and poorer overall health outcomes. It is incumbent on us as physicians to take an active role in speaking up for our patients. The importance of advocacy efforts to change policy (not politics) and continue to push for improvement in the increasingly challenging environments in which patients and physicians find themselves cannot be overstated. Multiple national organizations, including many orthopaedic and general surgery associations, have made statements advocating for change. The American College of Surgeons, in collaboration with many other medical organizations, has supported background checks, registration, licensure, firearm education and training, safe storage practices, red flag laws, addressing mental health issues, and more research to better inform an approach going forward and to address the root causes of violence. We encourage the orthopaedic surgery community to stand together to protect each other and our patients, both physically and mentally, with agreement on these principles.

Ethical Considerations of Artificial Intelligence in Health Care: Examining the Role of Generative Pretrained Transformer-4.

The integration of artificial intelligence technologies, such as large language models (LLMs), in health care holds potential for improved efficiency and decision support. However, ethical concerns must be addressed before widespread adoption. This article focuses on the ethical principles surrounding the use of Generative Pretrained Transformer-4 and its conversational model, ChatGPT, in healthcare settings. One concern is potential inaccuracies in generated content. LLMs can produce believable yet incorrect information, risking errors in medical records. Opacity of training data exacerbates this, hindering accuracy assessment. To mitigate, LLMs should train on precise, validated medical data sets. Model bias is another critical concern because LLMs may perpetuate biases from their training, leading to medically inaccurate and discriminatory responses. Sampling, programming, and compliance biases contribute necessitating careful consideration to avoid perpetuating harmful stereotypes. Privacy is paramount in health care, using public LLMs raises risks. Strict data-sharing agreements and Health Insurance Portability and Accountability Act (HIPAA)-compliant training protocols are necessary to protect patient privacy. Although artificial intelligence technologies offer promising opportunities in health care, careful consideration of ethical principles is crucial. Addressing concerns of inaccuracy, bias, and privacy will ensure responsible and patient-centered implementation, benefiting both healthcare professionals and patients.

The evolving roles of Wnt signaling in stem cell proliferation and differentiation, the development of human diseases, and therapeutic opportunities.

The evolutionarily conserved Wnt signaling pathway plays a central role in development and adult tissue homeostasis across species. Wnt proteins are secreted, lipid-modified signaling molecules that activate the canonical (ß-catenin dependent) and non-canonical (ß-catenin independent) Wnt signaling pathways. Cellular behaviors such as proliferation, differentiation, maturation, and proper body-axis specification are carried out by the canonical pathway, which is the best characterized of the known Wnt signaling paths. Wnt signaling has emerged as an important factor in stem cell biology and is known to affect the self-renewal of stem cells in various tissues. This includes but is not limited to embryonic, hematopoietic, mesenchymal, gut, neural, and epidermal stem cells. Wnt signaling has also been implicated in tumor cells that exhibit stem cell-like properties. Wnt signaling is crucial for bone formation and presents a potential target for the development of therapeutics for bone disorders. Not surprisingly, aberrant Wnt signaling is also associated with a wide variety of diseases, including cancer. Mutations of Wnt pathway members in cancer can lead to unchecked cell proliferation, epithelial-mesenchymal transition, and metastasis. Altogether, advances in the understanding of dysregulated Wnt signaling in disease have paved the way for the development of novel therapeutics that target components of the Wnt pathway. Beginning with a brief overview of the mechanisms of canonical and non-canonical Wnt, this review aims to summarize the current knowledge of Wnt signaling in stem cells, aberrations to the Wnt pathway associated with diseases, and novel therapeutics targeting the Wnt pathway in preclinical and clinical studies.

Are Social Deprivation and Low Traditional Health Literacy Associated With Higher PROMIS CAT Completion in Orthopaedic Surgery?

BACKGROUND: The Patient-Reported Outcomes Measurement Information System® (PROMIS®) may be used to assess an individual patient's perspective of their physical, mental, and social health through either standard or computer adaptive testing (CAT) patient questionnaires. These questionnaires are used across disciplines; however, they have seen considerable application in orthopaedic surgery. Patient characteristics associated with PROMIS CAT completion have not been examined within the context of social determinants of health, such as social deprivation or health literacy, nor has patient understanding of the content of PROMIS CAT been assessed. QUESTIONS/PURPOSES: (1) What patient demographics, including social deprivation, are associated with completion of PROMIS CAT questionnaires? (2) Is health literacy level associated with completion of PROMIS CAT questionnaires? (3) Do patients with lower health literacy have a higher odds of completing PROMIS CAT without fully understanding the content? METHODS: Between June 2022 and August 2022, a cross-sectional study was performed via a paper survey administered to patients at a single, urban, quaternary academic medical center in orthopaedic subspecialty clinics of foot and ankle, trauma, and hand/upper extremity surgeons. We considered all English-speaking patients aged 18 or older, including those with limited reading and/or writing abilities, as eligible provided they received an iPad in clinic to complete the PROMIS CAT questionnaire as part of their routine standard clinical care or they completed the questionnaire via a patient portal before the visit. In all, 946 patients were considered eligible during the study period and a convenience sample of 36% (339 of 946) of patients was approached for inclusion due to clinic time constraints. Fifteen percent (52 of 339) declined to participate, leaving 85% (287 of 339) of patients for analysis here. Median (range) age of study participants was 49 years (35 to 64). Fifty-eight percent (167 of 287) of study participants self-identified as non-Hispanic Black or African American and 26% (75 of 287) as non-Hispanic White. Even proportions were observed across education levels (high school graduate or less, 29% [82 of 287]; some college, 25% [73 of 287]; college graduate, 25% [71 of 287]; advanced degree, 20% [58 of 287]). Eighteen percent (52 of 287) of patients reported an annual income bracket of USD 0 to 13,000, and 17% (48 of 287) reported more than USD 120,000. Forty-six percent (132 of 287) of patients worked full-time, 21% (59 of 287) were retired, and 23% (66 of 287) were unemployed or on disability. The primary outcome of interest was self-reported PROMIS CAT questionnaire completion grouped as: fully completed, partially completed, or no part completed. Overall, self-reported PROMIS CAT questionnaire completion proportions were: 80% (229 of 287) full completion, 13% (37 of 287) partial completion, and 7% (21 of 287) no part completed. We collected the National Area Deprivation Index (ADI) score and the Brief Health Literacy Screening Tool (BRIEF) as part of the study survey to associate with level of completion. Additionally, patient understanding of PROMIS CAT was assessed through Likert-scaled responses to a study survey question that directly asked whether the patient understood all of the questions on the PROMIS CAT questionnaire. Responses to this question may have been limited by social desirability bias, and hence may overestimate how many individuals genuinely understood the questionnaire content. However, the benefit of this approach was it efficiently allowed us to estimate the ceiling effect of patient comprehension of PROMIS CAT and likely had a high degree of specificity for detecting lack of comprehension. RESULTS: ADI score adjusted for age was not associated with PROMIS CAT completion (partial completion OR 1.00 [95% CI 0.98 to 1.01]; p = 0.72, no part completed OR 1.01 [95% CI 0.99 to 1.03]; p = 0.45). Patients with lower health literacy scores, however, were more likely to not complete any part of their assigned questionnaires than patients with higher scores (no part completed OR 0.85 [95% CI 0.75 to 0.97]; p = 0.02). Additionally, 74% (26 of 35) of patients who did not fully understand all of the PROMIS CAT questionnaire questions still fully completed them-hence, 11% (26 of 229) of all patients who fully completed PROMIS CAT did not fully understand the content. Among patients self-reporting full completion of PROMIS CAT with health literacy data (99% [227 of 229]), patients with inadequate/marginal health literacy were more likely than patients with adequate health literacy to not fully understand all of the questions (21% [14 of 67] versus 8% [12 of 160], OR 3.26 [95% CI 1.42 to 7.49]; p = 0.005). CONCLUSION: Within an urban, socioeconomically diverse, orthopaedic patient population, health literacy was associated with PROMIS CAT questionnaire completion. Lower health literacy levels increased the likelihood of not completing any part of the assigned PROMIS CAT questionnaires. Additionally, patients completed PROMIS CAT without fully understanding the questions. This indicates that patient completion does not guarantee comprehension of the questions nor validity of their scores, even more so among patients with low health literacy. This is a substantive concern for fidelity of data gathered from PROMIS CAT. CLINICAL RELEVANCE: Clinical implementation of the PROMIS CAT in orthopaedic populations will benefit from further research into health literacy to increase questionnaire completion and to ensure that patients understand the content of the questions they are answering, which will increase the internal validity of the outcome measure.

Civilian Ballistic Arthrotomies: Infection Rates and Operative Versus Nonoperative Management.

OBJECTIVES: The purpose of this study was to determine whether a significant difference existed in the rate of infection after ballistic traumatic arthrotomy managed operatively compared with those managed without surgery. DESIGN: Retrospective cohort study. SETTING: Academic Level I Trauma Center. PATIENT SELECTION CRITERIA: Patients with ballistic traumatic arthrotomies of the shoulder, elbow, wrist, hip, knee, or ankle who received operative or nonoperative management. OUTCOME MEASURES AND COMPARISONS: The rates of infection and septic arthritis in those who received operative or nonoperative management. RESULTS: One hundred ninety-five patients were studied. Eighty patients were treated nonoperatively (Non-Op group), 16 patients were treated with formal irrigation and debridement in the operating room (I&D group), and 99 patients were treated with formal I&D and open reduction and internal fixation (ORIF) (I&D + ORIF group). Patients in all 3 groups received local wound care and systemic antibiotics. No patients in the Non-Op or I&D group developed an infection. Six patients in the I&D + ORIF group developed extra-articular postoperative infections requiring additional interventions. CONCLUSIONS: The infection rate in the I&D + ORIF group was consistent with the infection rates reported in orthopaedic literature after fixation alone. In addition, none of the infections were cases of septic arthritis. This suggests that traumatic arthrotomy does not increase the risk for infection beyond what is expected after fixation alone. Importantly, the Non-Op group represented a series of 80 patients who were treated nonoperatively without developing an infection, indicating that I&D may not be necessary to prevent infection after ballistic arthrotomy. The results suggest that septic arthritis after civilian ballistic arthrotomy is a rare complication regardless of the choice of treatment. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Depression, anxiety, and post-traumatic stress disorder following upper versus lower extremity fractures.

INTRODUCTION: Orthopaedic trauma has been linked to major depressive disorder (MDD), generalized anxiety disorder (GAD), and post-traumatic stress disorder (PTSD). Post-injury rates of psychiatric diagnoses and their relationship to various injury characteristics are not well characterized. We aimed to determine the association between orthopaedic trauma and MDD, GAD, and PTSD diagnoses at 5-year follow-up. METHODS: A national insurance claims database was used to create upper extremity fracture (UEF) and lower extremity fracture (LEF) cohorts, with further stratification by isolated versus multiple fractures. Patient undergoing elective upper or lower extremity orthopaedic procedures served as controls. Rates of post-injury psychiatric diagnoses were calculated. Univariate logistic regression was conducted after matching in a 1:1 ratio based on relevant comorbidities such as psychiatric history. All significant variables were included in multivariate analysis. RESULTS: A total of 308,578 UEF patients and 360,510 LEF patients were identified. Within the UEF cohort, the diagnosis rates following either isolated or multiple fractures were identified: MDD (25% to 30%), GAD (10% to 11%), and PTSD (4%). LEF cohort rates were as follows: MDD (30% to 38%), GAD (11% to 14%), and PTSD (4% to 7%). Compared to non-injured controls, both the UEF and LEF cohorts were associated with higher rates of all psychiatric diagnoses. In comparing UEF and LEF cohorts, isolated UEF was associated with MDD, GAD, and PTSD; however, multiple UEF was associated with MDD and GAD, whereas multiple LEF was associated with PTSD. CONCLUSION: Psychiatric pathology is prevalent following orthopaedic trauma. Even after controlling for psychiatric history, orthopaedic trauma is independently associated with post-injury psychiatric diagnoses and may be more predictive of PTSD and GAD than of MDD. Upper extremity fractures may portend higher psychiatric risk. With negative stigma surrounding mental health and the early role of orthopaedic surgeons in providing care, it is imperative to normalize psychiatric care with patients and discuss warning symptoms that may indicate the onset of psychiatric disorders. LEVEL OF EVIDENCE: Prognostic, Level III.

ChatGPT's Ability to Assist with Clinical Documentation: A Randomized Controlled Trial.

INTRODUCTION: Clinical documentation is a critical aspect of health care that enables healthcare providers to communicate effectively with each other and maintain accurate patient care records. Artificial intelligence tools, such as chatbots and virtual assistants, have the potential to assist healthcare providers in clinical documentation. ChatGPT is an artificial intelligence conversational model that generates human-like responses to text-based prompts. In this study, we sought to investigate ChatGPT's ability to assist with writing a history of present illness based on standardized patient histories. METHODS: A blinded, randomized controlled study was conducted to compare the use of typing, dictation, and ChatGPT as tools to document history of present illness (HPI) of standardized patient histories. Eleven study participants, consisting of medical students, orthopaedic surgery residents, and attending surgeons, completed three HPIs using a different documentation technique for each one. Participants were randomized into cohorts based on the type of documentation technique. Participants were asked to interview standardized patients and document the patient's history of present illness using their assigned method. RESULTS: ChatGPT was found to be intermediate for speed; dictation was fastest, but produced markedly longer and higher quality patient histories based on Physician Documentation Quality Instrument score compared with dictation and typing. However, ChatGPT included erroneous information in 36% of the documents. Poor agreement existed on the quality of patient histories between reviewers. DISCUSSION: Our study suggests that ChatGPT has the potential to improve clinical documentation by producing more comprehensive and organized HPIs. ChatGPT can generate longer and more detailed documentation compared with typing or dictation documentation methods. However, additional studies are needed to investigate and address concerns regarding privacy, bias, and accuracy of information.

The relationship between preoperative opioid use and adverse events following total shoulder arthroplasty.

Introduction: Few studies have analyzed the effect of preoperative opioid use on postoperative outcomes after total shoulder arthroplasty (TSA). Methods: Patients undergoing TSA were identified in the Pearldiver Humana Claims Dataset and stratified by level of preoperative opioid use. Primary outcomes were 90-day complications, readmissions, and revision surgery. Chi-square test and ANOVA were used to evaluate categorical and continuous variables respectively. A multivariable logistic regression analysis and a sub analysis excluding fracture as a primary diagnosis were completed. Results: 18,791 patients underwent aTSA and rTSA including 9933 opioid naïve patients, 3016 sporadic opioid users and 5842 persistent opioid users. Significant differences were found in complications (6.0% vs 6.1% vs 9.1%, p < .001), readmission (7.6% vs 8.2% vs 12.6%, p < .001), and revision procedures (1.1% vs 1.1% vs 2.3%, p < .001) which remained significant after excluding fractures. After adjusting for comorbidity burden, persistent opioid use was associated with increased likelihood of complications (OR 1.4, 1.2-1.6), readmission (OR 1.6, 1.5-1.8) and revision procedures (OR 1.9, 1.5-2.4). This association remained after excluding fractures. Conclusion: Persistent preoperative opioid use is associated with increased risk of early postoperative complications, readmission, and revision surgery for patients undergoing shoulder arthroplasty.

Corticosteroid injection of the knee within one month prior to meniscus repair increases the risk of repair failure requiring meniscectomy.

OBJECTIVE: Meniscal tears are common knee injuries with limited endogenous healing capacity. This study aimed to investigate the association between the timing and administration of preoperative intra-articular corticosteroid injections (CSIs) and the risk of subsequent meniscectomy following meniscus repair. METHODS: Using a national insurance claims database, patients aged 18-40 years undergoing meniscus repair within six months of tear diagnosis were studied. Patients were categorized based on whether they received preoperative CSIs within three intervals prior to repair. Multivariable logistic regression was used to analyze the risk of follow-up meniscectomy while controlling for various patient-related variables. RESULTS: Among 5,390 patients meeting inclusion criteria, 201 received preoperative CSIs. The CSI group was older and had higher rates of diabetes, obesity, and knee osteoarthritis. The overall rate of follow-up meniscectomy did not differ between groups. However, CSIs performed within one month prior to repair were associated with significantly higher odds of subsequent meniscectomy compared to CSIs performed between three and six months prior. Obesity, tobacco use, and knee osteoarthritis were also independently associated with higher risk, while increasing age was associated with lower risk. CONCLUSION: The study highlights an increased risk of repair failure requiring follow-up meniscectomy for patients receiving intra-articular CSIs within one month prior to meniscus repair. These findings suggest caution when considering CSIs as a treatment option for patients scheduled for meniscus repair. Further research is needed to establish optimal timing guidelines for CSIs in relation to meniscus repair and to understand the underlying mechanisms.

Bullet Fragment Retrieval During Intramedullary Nailing: A Report of 2 Cases.

CASE: Two young adult patients, 22 and 27 years, who sustained ballistic long bone fractures, presented for incarcerated, retained metallic fragments in the medullary canal, which blocked fixation. Owing to the presence and location of the fragments, each case required a bullectomy (removal of the metallic fragment) before intramedullary nail fixation because the projectile impeded the appropriate insertion of the intramedullary rod and, in one case, induced fracture malalignment. Attempts at removal using conventional tools did not provide adequate length or grasp of the retained projectile, necessitating the use of the novel technique. The Babcock Laparoscopic Endopath is an easy-to-use, ubiquitous tool that facilitates the removal of content within the intramedullary canal, including metallic or bony fragments. CONCLUSION: There is limited literature describing accessible, cost-effective techniques for the removal of intramedullary retained metallic foreign fragments when it is unremovable through conventional means. This article reports on a novel, minimally invasive technique for bullet removal from the intramedullary canal of the femur and tibia using the Babcock Laparoscopic Endopath, a tool typically used by urologists. Both patients were followed for at least 8 weeks postoperatively with no complications secondary to the procedure. The article describes the technique and advantages of using this readily available tool that is both flexible enough to navigate through the intramedullary canals as well as rigid enough to obtain and manipulate metallic objects.