Cost Variation in Temporizing External Fixation of Tibial Plateau Fractures.

BACKGROUND: Rising health care expenditures and declining reimbursements have generated interest in providing interventions of value. The use of external fixation is a commonly used intermediate procedure for the staged treatment of unstable fractures. External fixator constructs can vary in design and costs based on selected component configuration. The objective of this study was to evaluate cost variation and relationships to injury and noninjury characteristics in temporizing external fixation of tibial plateau fractures. We hypothesize that construct costs are highly variable and present no noticeable patterns with both injury and noninjury characteristics. METHODS: A retrospective review of tibial plateau fractures treated with initial temporizing external fixation between 2010 and 2016 at 2 Level I trauma centers was conducted. Fracture and patient characteristics including age, body mass index, AO/OTA classification, and Schatzker fracture classification were observed with construct cost. In addition, injury-independent characteristics of surgeon education, site of procedure, and date of procedure were evaluated with construct cost. Factors associated with cost variation were assessed using nonparametric comparative and goodness-of-fit regression tests. RESULTS: Two hundred twenty-one patient cases were reviewed. The mean knee spanning fixator construct cost was $4947 (95% confidence interval = $4742-$5152). The overall range in construct costs was from $1848 to $11,568. The mean duration of use was 16.4 days. No strong correlations were noted between construct cost and patient demographics (r = 0.02), fracture characteristics (r = 0.02), or injury-independent characteristics (r = 0.10). Finally, there was no significant difference between constructs of traumatologists and other orthopaedic surgeon subspecialists (P = 0.12). CONCLUSIONS: Temporizing external fixation of tibial plateau is a high-cost intervention per unit of time and exhibits massive variation in the mean cost. This presents an ideal opportunity for cost savings by reducing excessive variation in implant component selection. LEVEL OF EVIDENCE: Level III. Retrospective Cohort.

Ankle Fractures: An Expert Survey of Orthopaedic Trauma Association Members and Evidence-Based Treatment Recommendations.

OBJECTIVES: To describe current practice patterns of orthopaedic trauma experts regarding the management of ankle fractures, to review the current literature, and to provide recommendations for care based on a standardized grading system. DESIGN: Web-based survey. PARTICIPANTS: Orthopaedic Trauma Association (OTA) members. METHODS: A 27-item web-based questionnaire was advertised to members of the OTA. Using a cross-sectional survey study design, we evaluated the preferences in diagnosis and treatment of ankle fractures. RESULTS: One hundred sixty-six of 1967 OTA members (8.4%) completed the survey (16% of active members). There is considerable variability in the preferred method of diagnosis and treatment of ankle fractures among the members surveyed. Most responses are in keeping with best evidence available. CONCLUSIONS: Current controversy remains in the management of ankle fractures. This is reflected in the treatment preferences of the OTA members who responded to this survey. LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for authors for a complete description of levels of evidence.

Acute Compartment Syndrome: An Expert Survey of Orthopaedic Trauma Association Members.

OBJECTIVES: The goal of this study was to describe current opinions of orthopaedic trauma experts regarding acute compartment syndrome (ACS). DESIGN: Web-based survey. PARTICIPANTS: Active Orthopaedic Trauma Association (OTA) members. METHODS: A 25-item web-based questionnaire was advertised to active members of the OTA. Using a cross-sectional survey study design, we evaluated the perceived importance of ACS, as well as preferences in diagnosis and treatment. RESULTS: One hundred thirty-nine of 596 active OTA members (23%) completed the survey. ACS was believed to be clinically important and with severe sequelae, if missed. Responses indicated that diagnosis should be based on physical examination in an awake patient, and that intracompartmental pressure testing was valuable in the obtunded or unconscious patient. The diagnosis of ACS with monitoring should be made using the difference between diastolic blood pressure and intracompartmental pressure (ΔP) of ≤30 mm Hg. Once ACS is diagnosed, respondents indicated that fasciotomies should be performed as quickly as is reasonable (within 2 hours). The consensus for wound management was closure or skin grafting within 1-5 days later, and skin grafting was universally recommended if closure was delayed to >7 days. CONCLUSIONS: ACS is a challenging problem with poor outcomes if missed or inadequately treated. OTA members demonstrated agreement to many diagnostic and treatment choices for ACS. LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for Authors for a complete description of the levels of evidence.

Screw Stripping After Repeated Cortical Screw Insertion-Can We Trust the Cancellous "Bailout" Screw?

BACKGROUND: During osteosynthesis standard nonlocking cortical screws often require reinsertion, raising concern over possible decrease in their effectiveness. This study aims to quantify that potential loss of fixation with reinsertions as well as examine the ability of a cancellous "bailout screw" to regain insertion torque in a previously stripped screw hole. METHODS: Four different types of bone surrogates were chosen to represent normal cortical bone, osteoporotic cortical bone, high-density (normal) cancellous bone, and low-density (osteoporotic) cancellous bone; nonlocked 3.5-mm cortical screws were inserted into the predrilled holes 1, 2, 3, 4, or 5 times before being torqued maximally to the point of stripping. A 4.0-mm cancellous "bailout" screw was then placed into the same hole and torqued until stripping. Torque was measured continuously using a torque-measuring screwdriver and maximal insertion torque (MIT) of 3.5 and 4.0 screws before stripping was recorded. RESULTS: MIT decreased with reinsertion of nonlocked cortical screws. By the third reinsertion in all but the normal bone surrogates, the screws lost approximately one third to one half of their original MIT (50%-71% of original torque). The bailout screw succeeded in restoring the original MIT in the osteoporotic cancellous bone surrogate and the normal cortical bone surrogate. In the normal cancellous and osteoporotic cortical bone surrogates, the bailout screw was only able to restore an average of 50% (range 31%-63%) of the original MIT. CONCLUSIONS: Screw reinsertion may significantly reduce the MIT of 3.5-mm nonlocked cortical screws. Use of the bailout cancellous screw for a stripped cortical screw should be expected to restore MIT only in normal cortical bone and osteoporotic cancellous bone. In other scenarios, the bailout screw should not be expected to uniformly restore full insertion torque.

Complications and Predictors of Need for Return to the Operating Room in the Treatment of Supracondylar Humerus Fractures in Children.

UNLABELLED: Supracondylar humerus fractures are common pediatric injuries. Little is known about the risk factors for repeat operative procedures. A retrospective chart review of 709 patients treated for a displaced supracondylar humerus fracture was performed to identify risk factors for return to the operating room during the initial post-operative period. Deviations of routine fracture care were recorded and complication rates were compared between Gartland type 2 and 3 fractures using logistic regression. Type 3 fractures were found to have a higher complication rate, and, specifically, more peri-operative nerve palsies, more likely to need to return to the operating room for hardware removal, to lose fracture reduction, and require a return to the operating room for any reason. Five risk factors which may require returning to the operating room were identified: younger patient age, left sided fractures, type 3 fractures, peri-operative nerve palsy, and post-operative infection. In conclusion, Gartland type 3 supracondylar humerus fractures are associated with more complications then type 2 fractures. Risk factors for the need to return to the operating room in the post-operative period include: younger patient age, left sided fractures, type 3 fractures, peri-operative nerve palsy, and post-operative infection. Patients with these risk factors should be considered at risk for return to the OR and fracture fixation and follow up protocols should be adjusted for this risk. LEVEL OF EVIDENCE: Prognostic Study, Level II.

The perfect reduction: approaches and techniques.

Anatomic reduction of femoral neck fractures is difficult to obtain in a closed fashion. Open reduction provides for direct and controlled manipulation of fracture fragments. This can be accomplished via multiple approaches. The anterolateral, or Watson-Jones, approach or Smith-Petersen, or direct anterior, approach are the two most frequently used. Percutaneous techniques have also been described, though they lack the visual confirmation of reduction of a traditional open approach. These can be performed using a fracture table or with a free leg on a radiolucent table in either supine or lateral positions. Knowledge of the hip and pelvis anatomy is crucial for the preservation of critical femoral neck vasculature. Intra-operative fluoroscopy together with direct visualization provides the framework for successful manipulation of the fracture fragments, temporary stabilization, and ultimately fracture fixation.

Detection of periprosthetic infections with use of ribosomal RNA-based polymerase chain reaction.

BACKGROUND: Previously described molecular biology techniques used to detect periprosthetic infections have been complicated by false-positive results. We have reported the development of a messenger RNA (mRNA)-based procedure to reduce these false-positive results. The limitations of this procedure are the lack of a universal target and reduced sensitivity due to a low concentration of bacterial mRNAs in test samples. The objective of the present study was to determine whether reverse transcription-quantitative polymerase chain reaction (RT-qPCR) using universal primers can be used to detect the more abundant bacterial ribosomal RNA (rRNA) as an indicator of periprosthetic infection. METHODS: Serial dilutions of simulated synovial fluid infections were analyzed with rRNA RT-qPCR to determine the detection limit of this assay. Escherichia coli cultures treated with gentamicin were analyzed with RT-qPCR over a twenty-day time course to determine the degradation of rRNA as compared with the decrease in the viable cell count as determined by means of cell plating. As a proof of concept, group-specific polymerase chain reaction primers were developed for Streptococcus species and were tested against fifteen orthopaedically relevant organisms to show the potential for speciation with this assay. Sixty-four patients with a symptomatic effusion at the site of a total knee arthroplasty were enrolled, and complete patient information was documented in a prospective manner. Synovial fluid analysis with rRNA RT-qPCR was performed in a blind fashion. RESULTS: The rRNA RT-qPCR assay was able to detect as few as 590 colony forming units/mL of Staphylococcus aureus and 2900 colony forming units/mL of Escherichia coli. The rRNA RT-qPCR signal closely followed cell death, pointing to its potential use as a viability marker. Three group-specific primer sets correctly identified their intended targets without amplifying closely related species. Clinically, the test correctly identified all six patients with a confirmed infection and all fifty patients who clearly did not have an infection. Eight patients had some laboratory or clinical signs of infection, but their status could not be confirmed. Infection was indicated by rRNA RT-qPCR in three of these patients who had elevated synovial fluid white blood-cell counts but negative results on culture. For statistical purposes, all patients who were categorized as indeterminate were considered to have an infection for the purpose of analysis, for a prevalence of 22% in this cohort. CONCLUSIONS: With respect to current diagnostic tests, rRNA-based RT-qPCR demonstrated 100% specificity and positive predictive value with a sensitivity equivalent to that of intraoperative culture. The RT-qPCR signal followed bacterial culture trends but exhibited detectable level for seven days after sterilization, allowing for the detection of infection after the antibiotic administration. These findings indicate that rRNA RT-qPCR is a sensitive and reliable test that retains the universal detection and speciation of DNA-based methods while functioning as a viability indicator.

Altered fatty acid composition of dopaminergic neurons expressing alpha-synuclein and human brains with alpha-synucleinopathies.

Alpha-synuclein (alphaS) is an abundant neuronal protein that accumulates in insoluble inclusions in Parkinson's disease (PD) and the related disorder, dementia with Lewy bodies (DLB). A central question about the role of alphaS in the pathogenesis of PD and DLB concerns how this normally soluble protein assembles into insoluble aggregates associated with neuronal dysfunction. We recently detected highly soluble oligomers of alphaS in normal brain supernatants and observed their augmentation in PD and DLB brains. Further, we found that polyunsaturated fatty acids (PUFAs) enhanced alphaS oligomerization in intact mesencephalic neuronal cells. We now report the presence of elevated PUFA levels in PD and DLB brain soluble fractions. Higher PUFA levels were also detected in the supernatants and high-speed membrane fractions of neuronal cells over-expressing wild-type or PD-causing mutant alphaS. This increased PUFA content in the membrane fraction was accompanied by increased membrane fluidity in the alphaS overexpressing neurons. In accord, membrane fluidity and the levels of certain PUFAs were decreased in the brains of mice genetically deleted of alphaS. Together with our earlier observations, these results suggest that alphaS-PUFA interactions help regulate neuronal PUFA levels as well as the oligomerization state of alphaS, both normally and in human synucleinopathies.

Calix[4]arene, calix[4]resorcarene, and cyclodextrin derivatives and their lanthanide complexes as chiral NMR shift reagents.

Calix[4]arenes, calix[4]resorcarenes, and anionic cyclodextrin derivatives were examined as chiral NMR solvating agents. The calix[4]arenes were prepared by attachment of amino acids through the hydroxyl groups of the phenol rings. Chloroform-, methanol-, and water-soluble derivatives were prepared and tested with a range of substrates. Chloroform-soluble chiral calix[4]resorcarenes were prepared by attachment of chiral primary and secondary amines and examined in NMR applications with a variety of substrates. Sulfated and carboxymethylated beta-cyclodextrin are effective at causing enantiomeric discrimination in the (1)H NMR spectra of organic cations. Lanthanide ions associate at the carboxymethyl groups and cause sizeable shifts and enhancements in enantiomeric discrimination in the spectra of organic cations. The enhancements caused by the lanthanide ion are large enough that much lower concentrations of the cyclodextrin can be used as compared to conventional analyses.

Resolvins: a family of bioactive products of omega-3 fatty acid transformation circuits initiated by aspirin treatment that counter proinflammation signals.

Aspirin (ASA) is unique among current therapies because it acetylates cyclooxygenase (COX)-2 enabling the biosynthesis of R-containing precursors of endogenous antiinflammatory mediators. Here, we report that lipidomic analysis of exudates obtained in the resolution phase from mice treated with ASA and docosahexaenoic acid (DHA) (C22:6) produce a novel family of bioactive 17R-hydroxy-containing di- and tri-hydroxy-docosanoids termed resolvins. Murine brain treated with aspirin produced endogenous 17R-hydroxydocosahexaenoic acid as did human microglial cells. Human COX-2 converted DHA to 13-hydroxy-DHA that switched with ASA to 17R-HDHA that also proved a major route in hypoxic endothelial cells. Human neutrophils transformed COX-2-ASA-derived 17R-hydroxy-DHA into two sets of novel di- and trihydroxy products; one initiated via oxygenation at carbon 7 and the other at carbon 4. These compounds inhibited (IC(50) approximately 50 pM) microglial cell cytokine expression and in vivo dermal inflammation and peritonitis at ng doses, reducing 40-80% leukocytic exudates. These results indicate that exudates, vascular, leukocytes and neural cells treated with aspirin convert DHA to novel 17R-hydroxy series of docosanoids that are potent regulators. These biosynthetic pathways utilize omega-3 DHA and EPA during multicellular events in resolution to produce a family of protective compounds, i.e., resolvins, that enhance proresolution status.