Treatment approach for coexisting chest wall fractures and unstable thoracolumbar spine fractures in polytrauma patients requiring prone spine surgery.

Concomitant chest wall fractures (sternal and/or rib fractures) with unstable thoracolumbar fractures that require surgical fixation are rare but highly morbid injuries that mandate a multidisciplinary approach to treatment. There is limited evidence in the literature regarding optimal timing and order of surgical fixation of these patients with multiple injuries. Here, we present our experience with two patients at a single institution that demonstrates the challenges that present with this patient population. We advocate for earlier fixation of the chest wall fractures in the appropriately indicated patients, prior to prone positioning for spinal fixation.

Lumbar Vertebral Body Tethering: Single Center Outcomes and Reoperations in a Consecutive Series of 106 Patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate the outcomes and reoperation rates in patients with adolescent idiopathic scoliosis (AIS) undergoing lumbar anterior vertebral body tethering (AVBT). SUMMARY OF BACKGROUND DATA: Anterior vertebral body tethering (AVBT) is a viable option in growing children. The benefit of motion preservation must be balanced by a higher reoperation rate. A paucity of reports has addressed lumbar AVBT. METHODS: A single-center retrospective study was conducted to identify all patients who underwent lumbar AVBT (lowest instrumented vertebra L3 or L4) with a minimum 2 years of follow-up. Clinical and radiographic parameters, including complications and reoperations, were also collected. Statistical analysis was performed using Student's t-test for qualitative variables. RESULTS: From a dataset of 551 patients, we identified 106 patients (89% female) who underwent a lumbar AVBT (33 lumbar only, 73 bilateral thoracic/lumbar) with mean follow-up of 4.1±1.6 years at which point 85% (90/106) had reached skeletal maturity. Preoperatively, these patients were skeletally immature (age: 12.8±1.3 y, Sanders: 3.3±0.8, R=0.6±0.9) with a lumbar coronal curve angle of 49.6°±11.2 which corrected to 19.9°±11.2 (P <0.0001) at most recent follow-up. At the latest follow-up, 76.4% (81/106) of the patients harbored a coronal curve angle of < 30°. Twenty patients (18.9%) underwent 23 reoperations, with overcorrection being the most common (10/23, 43%). Broken tethers led to reoperation in 3 instances (3/23, 13%). Six patients in the cohort needed a posterior spinal fusion (6/106, 5.4%). CONCLUSIONS: Vertebral body tethering is a viable treatment option for skeletally immature patients with idiopathic scoliosis. This report is the largest to date for lumbar AVBT, highlighting that 84% of patients harbored a curve < 35° at the latest follow-up but with an 18.9% reoperation rate. LEVEL OF EVIDENCE: 3.

Early outcomes in hybrid fixation for idiopathic scoliosis: posterior fusion combined with anterior vertebral body tethering. Patient series.

BACKGROUND: Anterior vertebral body tethering (AVBT) and posterior spinal fusion (PSF) are options for patients with idiopathic scoliosis. Combining both procedures in patients with double curves, a procedure in which PSF is performed for the thoracic curve and AVBT for the lumbar curve, provides maximal correction of the thoracic curve with a theoretical maintenance of motion in the lumbar spine. OBSERVATIONS: The authors retrospectively reviewed 20 skeletally immature patients diagnosed with idiopathic scoliosis at a single institution with an average age of 12.7 ± 1.6 years and who had undergone hybrid treatment with an average follow-up of 8 months. The PSF procedures averaged 276 ± 63 minutes with 442.8 ± 295 mL of blood loss, and the AVBT averaged 275 ± 54 minutes with 118.3 ± 80 mL of blood loss. Following the hybrid correction, the thoracic and lumbar coronal curve angles improved from 67.6° to 21.6° and from 65.2° to 24°, respectively. The three-dimensional kyphosis improved from 3.3° to 24°. LESSONS: A combined approach of PSF and AVBT is safe and effective for idiopathic scoliosis. This approach combines the gold standard of thoracic fusion with the motion preservation benefits of AVBT in the lumbar spine. This study will continue to refine indications for AVBT.

The Association of Delirium with Perioperative Complications in Primary Elective Total Hip Arthroplasty.

BACKGROUND: Our goal was to determine whether postoperative delirium is associated with inpatient complication rates after primary elective total hip arthroplasty (THA). METHODS: Using the National Inpatient Sample, we analyzed records of patients who underwent primary elective THA from 2000 through 2009 to identify patients with delirium (n = 13,551) and without delirium (n = 1,992,971) and to assess major perioperative complications (acute renal failure, death, myocardial infarction, pneumonia, pulmonary embolism, and stroke) and minor perioperative complications (deep vein thrombosis, dislocation, general procedural complication, hematoma, seroma, and wound infection). Patient age, sex, length of hospital stay, and number of comorbidities were assessed. We used multivariate logistic regression to determine the association of delirium with complication rates (significance, p < 0.01). RESULTS: Patients with delirium were older (mean, 75 ± 0.2 vs. 65 ± 0.1 years), were more likely to be male (56% vs. 52%), had longer hospital stays (mean, 5.7 ± 0.07 vs. 3.8 ± 0.02 days), and had more comorbidities (mean, 2.8 ± 0.03 vs. 1.4 ± 0.01) (all p < 0.001) versus patients without delirium. Patients with delirium were more likely to have major (11% vs. 3%) and minor (17% vs. 7%) perioperative complications versus patients without delirium (both p < 0.001). When controlling for age, sex, and number of comorbidities, delirium was independently associated with major and minor complications (odds ratio, 2.0; 95% confidence interval, 1.7 to 2.3). CONCLUSIONS: Delirium is an independent risk factor for major and minor perioperative complications after primary elective THA.

Post-Discharge Care Duration, Charges, and Outcomes Among Medicare Patients After Primary Total Hip and Knee Arthroplasty.

BACKGROUND: In April 2016, the U.S. Centers for Medicare & Medicaid Services initiated mandatory 90-day bundled payments for total hip and knee arthroplasty for much of the country. Our goal was to determine duration of care, 90-day charges, and readmission rates by discharge disposition and U.S. region after hip or knee arthroplasty. METHODS: Using the 2008 Medicare Provider Analysis and Review database 100% sample, we identified patients who had undergone elective primary total hip or knee arthroplasty. We collected data on patient age, sex, comorbidities, U.S. Census region, discharge disposition, duration of care, 90-day charges, and readmission. Multivariate regression was used to assess factors associated with readmission (logistic) and charges (linear). Significance was set at p < 0.01. RESULTS: Patients undergoing 138,842 total hip arthroplasties were discharged to home (18%), home health care (34%), extended-care facilities (35%), and inpatient rehabilitation (13%); patients undergoing 329,233 total knee arthroplasties were discharged to home (21%), home health care (38%), extended-care facilities (31%), and inpatient rehabilitation (10%). Patients in the Northeast were more likely to be discharged to extended-care facilities or inpatient rehabilitation than patients in other regions. Patients in the West had the highest 90-day charges. Approximately 70% of patients were discharged home from extended-care facilities, whereas after inpatient rehabilitation, >50% of patients received home health care. Among those discharged to home, 90-day readmission rates were highest in the South (9.6%) for patients undergoing total hip arthroplasty and in the Midwest (8.7%) and the South (8.5%) for patients undergoing total knee arthroplasty. Having ≥4 comorbidities, followed by discharge to inpatient rehabilitation or an extended-care facility, had the strongest associations with readmission, whereas the region of the West and the discharge disposition to inpatient rehabilitation had the strongest association with higher charges. CONCLUSIONS: Among Medicare patients, discharge disposition and number of comorbidities were most strongly associated with readmission. Inpatient rehabilitation and the West region had the strongest associations with higher charges. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Implementation of TeamSTEPPS in Orthopaedic Surgery.

An Institute of Medicine report published in 2000 brought attention to the devastating consequences of medical errors. The report estimated that 98,000 deaths occurred in US hospitals each year as a result of medical errors and spawned investigations into factors that are associated with medical errors as well as strategies to avoid them. Taking cues from high-reliability organizations, such as the airline industry, evidence-based tools were developed to minimize human risk factors and foster teamwork, communication, and other skills that are essential to patient safety and quality. Orthopaedic surgeons are in a unique position to advocate for patients and to lead healthcare teams through the cultural changes that are necessary to avoid harm and improve outcomes. The American Academy of Orthopaedic Surgeons has made a commitment to educate interdisciplinary healthcare teams and uses TeamSTEPPS to educate orthopaedic surgeons on the knowledge, skills, and attitudes that are necessary to develop teamwork and improve patient safety and the quality of care. Orthopaedic surgeons should understand the need for improved teamwork and the resources that are available to shape the cultural changes that are necessary to avoid harm and improve outcomes.

Osteonecrosis in Sickle Cell Disease.

Osteonecrosis is one of the most devastating musculoskeletal manifestations of sickle cell disease and most commonly affects the femoral head. Although the exact pathophysiology of this condition in patients with sickle cell disease is unknown, it is suggested that red cell sickling and repetitive vaso-occlusion may be associated with tissue hypoxia, inflammation, and subsequent bone necrosis and collapse. If left untreated, osteonecrosis can be extremely debilitating and may lead to severe pain, loss of function, and degenerative joint changes. Although several conservative management approaches exist, total joint arthroplasty remains the most effective treatment intervention. A multidisciplinary approach among the primary care physician, hematologist, and orthopedic surgeon is essential in optimizing patient management.

Evolution of cichlid vision via trans-regulatory divergence.

BACKGROUND: Phenotypic evolution may occur through mutations that affect either the structure or expression of protein-coding genes. Although the evolution of color vision has historically been attributed to structural mutations within the opsin genes, recent research has shown that opsin regulatory mutations can also tune photoreceptor sensitivity and color vision. Visual sensitivity in African cichlid fishes varies as a result of the differential expression of seven opsin genes. We crossed cichlid species that express different opsin gene sets and scanned their genome for expression Quantitative Trait Loci (eQTL) responsible for these differences. Our results shed light on the role that different structural, cis-, and trans-regulatory mutations play in the evolution of color vision. RESULTS: We identified 11 eQTL that contribute to the divergent expression of five opsin genes. On three linkage groups, several eQTL formed regulatory "hotspots" associated with the expression of multiple opsins. Importantly, however, the majority of the eQTL we identified (8/11 or 73%) occur on linkage groups located trans to the opsin genes, suggesting that cichlid color vision has evolved primarily via trans-regulatory divergence. By modeling the impact of just two of these trans-regulatory eQTL, we show that opsin regulatory mutations can alter cichlid photoreceptor sensitivity and color vision at least as much as opsin structural mutations can. CONCLUSIONS: Combined with previous work, we demonstrate that the evolution of cichlid color vision results from the interplay of structural, cis-, and especially trans-regulatory loci. Although there are numerous examples of structural and cis-regulatory mutations that contribute to phenotypic evolution, our results suggest that trans-regulatory mutations could contribute to phenotypic divergence more commonly than previously expected, especially in systems like color vision, where compensatory changes in the expression of multiple genes are required in order to produce functional phenotypes.

Divergence in cis-regulatory sequences surrounding the opsin gene arrays of African cichlid fishes.

BACKGROUND: Divergence within cis-regulatory sequences may contribute to the adaptive evolution of gene expression, but functional alleles in these regions are difficult to identify without abundant genomic resources. Among African cichlid fishes, the differential expression of seven opsin genes has produced adaptive differences in visual sensitivity. Quantitative genetic analysis suggests that cis-regulatory alleles near the SWS2-LWS opsins may contribute to this variation. Here, we sequence BACs containing the opsin genes of two cichlids, Oreochromis niloticus and Metriaclima zebra. We use phylogenetic footprinting and shadowing to examine divergence in conserved non-coding elements, promoter sequences, and 3'-UTRs surrounding each opsin in search of candidate cis-regulatory sequences that influence cichlid opsin expression. RESULTS: We identified 20 conserved non-coding elements surrounding the opsins of cichlids and other teleosts, including one known enhancer and a retinal microRNA. Most conserved elements contained computationally-predicted binding sites that correspond to transcription factors that function in vertebrate opsin expression; O. niloticus and M. zebra were significantly divergent in two of these. Similarly, we found a large number of relevant transcription factor binding sites within each opsin's proximal promoter, and identified five opsins that were considerably divergent in both expression and the number of transcription factor binding sites shared between O. niloticus and M. zebra. We also found several microRNA target sites within the 3'-UTR of each opsin, including two 3'-UTRs that differ significantly between O. niloticus and M. zebra. Finally, we examined interspecific divergence among 18 phenotypically diverse cichlids from Lake Malawi for one conserved non-coding element, two 3'-UTRs, and five opsin proximal promoters. We found that all regions were highly conserved with some evidence of CRX transcription factor binding site turnover. We also found three SNPs within two opsin promoters and one non-coding element that had weak association with cichlid opsin expression. CONCLUSIONS: This study is the first to systematically search the opsins of cichlids for putative cis-regulatory sequences. Although many putative regulatory regions are highly conserved across a large number of phenotypically diverse cichlids, we found at least nine divergent sequences that could contribute to opsin expression differences in cis and stand out as candidates for future functional analyses.