Patient satisfaction after lower limb replantation surgery for traumatic amputation - a qualitative study.

BACKGROUND: The majority of published literature clinically assesses surgical outcomes after lower limb replantation for traumatic amputations. However, patients' satisfaction and quality of life may not be accurately measured through rigid scoring using standardized patient reported outcome measures. PURPOSE: The aim of this study was to qualitatively assess patient satisfaction and factors associated with achieving good outcomes after successful lower limb replantation surgery. METHODS: A semi-structured interview was conducted with 12 patients who underwent lower limb replantation surgery following traumatic amputation injuries. The interview focused on the patients' experience and satisfaction throughout their injury, surgical journey, rehabilitation and reintegration into their communities. An inductive and deductive thematic analysis was applied using the recorded transcripts to evaluate the overall satisfaction of the patients after lower limb replantation surgery. RESULTS: The following observations emerged from the structured themes among all the patients interviewed: (1) Family and social support was significantly associated with improved qualities of life and satisfaction after lower limb replantation; (2) Patients were generally satisfied with their outcomes despite limitations in physical capabilities; (3) Satisfaction was associated with acceptance of their cosmetic deformity; (4) Social integration and being able to participate in a meaningful manner was associated with greater satisfaction after recovery. CONCLUSIONS: Patients who undergo lower limb replantation can have a significantly improved quality of life if they have strong social support, are able to contribute in a meaningful manner to their communities after surgery, and are accepting of their cosmetic deficiencies.

Mitochondria-lysosome-related organelles mediate mitochondrial clearance during cellular dedifferentiation.

Dysfunctional mitochondria are removed via multiple pathways, such as mitophagy, a selective autophagy process. Here, we identify an intracellular hybrid mitochondria-lysosome organelle (termed the mitochondria-lysosome-related organelle [MLRO]), which regulates mitochondrial homeostasis independent of canonical mitophagy during hepatocyte dedifferentiation. The MLRO is an electron-dense organelle that has either a single or double membrane with both mitochondria and lysosome markers. Mechanistically, the MLRO is likely formed from the fusion of mitochondria-derived vesicles (MDVs) with lysosomes through a PARKIN-, ATG5-, and DRP1-independent process, which is negatively regulated by transcription factor EB (TFEB) and associated with mitochondrial protein degradation and hepatocyte dedifferentiation. The MLRO, which is galectin-3 positive, is reminiscent of damaged lysosome and could be cleared by overexpression of TFEB, resulting in attenuation of hepatocyte dedifferentiation. Together, results from this study suggest that the MLRO may act as an alternative mechanism for mitochondrial quality control independent of canonical autophagy/mitophagy involved in cell dedifferentiation.

Return to Driving Is Safe 6 Weeks After Anterior Cervical Surgery for Symptomatic Cervical Degenerative Disc Disease.

STUDY DESIGN: Prospective Cohort Study. OBJECTIVES: This study aims to determine the timing and clinical parameters for a safe return to driving. SUMMARY OF BACKGROUND DATE: Returning to driving after cervical spine surgery remains a controversial topic, with no clear consensus on how to best assess a patient's fitness to drive. Previous studies using brake reaction time or subjective questionnaires recommend a return to driving 6 weeks after surgery. METHODS: Patients above 18 years of age who underwent anterior cervical spine surgery for symptomatic cervical degenerative disk disease and possessed a valid motorcar driving license were recruited from 2018 to 2020. Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA) scores, range of motion, and functional strength of the cervical spine were collected preoperatively and at 2-, 4-, 6- and 12 weeks postsurgery. Patients underwent a standard functional driving assessment protocol at the institution to determine their fitness to drive. This comprised of a clinic-based off-road screening tests and on-road driving test in a real-world environment. RESULTS: Twenty-one patients were recruited. The mean age was 56.6±8.9 years. Eighty-one percent of the patients passed the on-road driving assessment at 6 weeks. Patients who passed the driving assessment had lower mean NDI scores, 3.4±3.1 versus 10.8±8.0 ( P =0.006), and higher mean mJOA scores 16.1±0.6 versus 15.0±1.8 ( P =0.045). Patients who passed the driving assessment also had higher functional cervical flexor strength, 21.1s±5.8s versus 13.0s±10.2s ( P =0.042) in a supine position but not correlated with a range of motion of the spine in all directions. CONCLUSION: Most patients undergoing single or dual-level anterior cervical surgery for symptomatic cervical degenerative disk disease demonstrate the ability to pass a standardized driving assessment and are safe to return to driving more than 6 weeks after surgery. Driving ability appears to be correlated with NDI scores ≤3 ( P =0.006), mJOA scores ≥16 ( P =0.045), and cervical flexion endurance of ≥21s ( P =0.042). LEVEL OF EVIDENCE: Level II.

An Orthopaedic Surgeon Led Osteoporosis (OSLO) Model of Care reduces early recurrent fracture rates and improves treatment compliance in patients treated for osteoporotic fractures.

This study aims to evaluate the efficacy of an Orthopaedic Surgeon Led Osteoporosis Model of Care (OSLO-MoC) in improving care of patients with primary osteoporotic fractures. The OSLO-MOC has shown to be effective in improving osteoporotic medication initiation and compliance and reducing secondary fracture rates in patients. PURPOSE: This study aims to evaluate the efficacy of an Orthopaedic Surgeon Led Osteoporosis Model of Care (OSLO-MoC) as compared to a Case Manager Led Osteoporosis Model of Care (CMLO-MoC) in reducing early osteoporotic re-fracture rates and treatment compliance in patients. METHODS: This was a single centre, retrospective, comparative cohort study of all patients screened and treated for secondary osteoporotic fracture prevention from the 2008 to 2018 at an orthopaedic surgical unit. From the 2008 to 2013, patients were recruited under the CMLO-MoC and from 2014 to 2018, under the OSLO-MOC. Logistics regression analysis was used to identify significant predictors such as OSLO-MOC implementation, gender, ethnicity, marital status and education level for patient recruitment, treatment compliance and secondary fracture rates at 12-month follow-up. RESULTS: Over a 10-year period, 7388 patients were screened of which 2855 patients were eligible for analysis. A total of 1234 patients were recruited under CMLO-MoC and 1621 patients under OSLO-MOC. Implementation of the OSLO-MOC was associated with greater patient recruitment, OR 1.26 (95%CI 1.06-1.49, P = 0.007). Of the 2855 patients recruited, OSLO-MOC implementation, OR 2.61 (95%CI 2.03-3.36, P < 0.001), and a higher level of education, OR 1.428 (95%CI 1.02-1.43, P = 0.037), were associated with improved compliance to medication at 12 months. OSLO-MOC implementation was the only factor associated with reduced risk of secondary fractures at 12 months, OR 0.14 (95%CI 0.03-0.66, P = 0.013). CONCLUSION: The OSLO-MOC has shown to be effective in reducing the rate of re-fracture and osteoporotic medication initiation and compliance of patients. LEVEL OF EVIDENCE: IV.

Enhanced Recovery after Surgery for Knee Arthroplasty in the Era of COVID-19.

Enhanced recovery after surgery (ERAS) represents a paradigm shift in perioperative care, aimed at achieving early recovery for surgical patients, reducing length of hospital stay, and complications. The purpose of this study was to provide an insight of the impact of the COVID-19 on ERAS protocols for knee arthroplasty patients in a tertiary hospital and potential strategy changes for postpandemic practice. We retrospectively reviewed all cases that underwent surgery utilizing ERAS protocols in the quarter prior to the pandemic (fourth quarter of 2019) and during the first quarter of 2020 when the pandemic started. A review of the literature on ERAS protocols for knee arthroplasty during the COVID-19 pandemic was also performed and discussed. A total of 199 knee arthroplasties were performed in fourth quarter of 2019 as compared with 76 in the first quarter of 2020 during the COVID-19 outbreak. Patients who underwent surgery in the first quarter of 2020 had shorter inpatient stays (3.8 vs. 4.5 days), larger percentage of discharges by postoperative day 5 (86.8 vs. 74.9%), and a larger proportion of patients discharged to their own homes (68 vs. 54%). The overall complication rate (1.3 vs. 3%) and readmission within 30 days (2.6 vs. 2%) was similar between both groups. ERAS protocols appear to reduce hospital lengths of stay for patients undergoing knee arthroplasty without increasing the risk of short-term complications and readmissions. The beneficial effects of ERAS appear to be amplified by and are synchronous with the requirements of operating in the era of a pandemic.

Collaborative model of care between Orthopaedics and allied healthcare professionals trial (CONNACT) - a feasibility study in patients with knee osteoarthritis using a mixed method approach.

BACKGROUND: Osteoarthritis is a leading cause of global disability resulting in significant morbidity and cost to the healthcare system. Current guidelines recommend lifestyle changes such exercises and weight loss as first line treatment prior to surgical consideration. Our current model of care is inefficient with suboptimal allied health intervention for effective behaviour changes. A 12-week community based, individualized, multidisciplinary new model of care for knee osteoarthritis was developed in light of current deficiencies. METHODS: The primary aim of this study was to determine the feasibility of a full randomized controlled trial evaluating this new model of care using pre-defined progression criteria. The secondary aim was to optimize the intervention and study design through a process evaluation. A pilot exploratory, parallel arm, single blinded randomized trial design using a mixed method approach was utilized. Progression criteria for a full trial including key domains of patient recruitment and retention, outcome measure acceptability and improvement, adverse events were developed. The primary outcome measure was the Knee Injury and Osteoarthritis Outcome Score (KOOS) at baseline and 12-weeks. Secondary outcomes included quality of life, functional and psychological assessments. Semi-structured interviews were conducted with the patients at 12-weeks. RESULTS: 20 patients (3 males, 17 females) were randomized (10 intervention, 10 control). Intervention arm patients reported better improvements in their knee function, quality of life, psychological outcome, dietary improvement and weight loss compared to the control arm at 12-weeks. Semi-structured interviews revealed several themes pertaining to feasibility and intervention optimization. 5 out of the 6 progression criteria's domains were met (recruitment criteria not met). CONCLUSION: This pilot has demonstrated the feasibility of a full randomized control trial investigating the potential effectiveness of the new proposed model of care for knee osteoarthritis using pre-defined progression criteria and process evaluation. Results from the qualitative study were used to modify and improve the intervention content, delivery model and study design for a large effectiveness-implementation hybrid randomized control trial that is currently underway. TRIAL REGISTRATION: Retrospectively registered on 18 January 2019 at http://clinicaltrial.gov ID: NCT03809975 .

Orthopaedic surgery after COVID-19 - A blueprint for resuming elective surgery after a pandemic.

BACKGROUND: The COVID-19 outbreak was fraught with danger and despair as many medically necessary surgeries were cancelled to preserve precious healthcare resources and mitigate disease transmission. As the rate of infection starts to slow, healthcare facilities and economies attempt to return to normalcy in a graduated manner and the massive pent-up demand for surgeries needs to eventually be addressed in a systematic and equitable manner. MATERIALS AND METHODS: Guidelines from the Alliance of International Organizations of Orthopaedics and Traumatology, Orthopaedic Trauma Association, American College of Surgeons, American Society of Anaesthesiologists, Association of perioperative Registered Nurses, American Hospital Association, Centers for Medicare and Medicaid Services, World Health Organization and Centers for Disease Control and Prevention were evaluated and summarized into a working framework, relevant to orthopaedic surgeons. RESULTS: The guiding principles for restarting elective surgeries in a safe and acceptable manner include up-to-date disease awareness, projection and judicious management of equipment and facilities, effective human resource management, a fair and transparent system to prioritize cases, optimization of peri-operative workflows and continuous data gathering and clinical governance. CONCLUSION: The world was ill prepared for the initial COVID-19 outbreak. However, with effective forward planning, institutions can ramp-up elective surgical caseload in a safe and equitable manner.

Prospective Evaluation of the Time Required for Insertion of 380 Lumbar and Sacral Pedicle Screws Using Navigation with an Intraoperative 3-Dimensional Imaging System.

BACKGROUND: The aim of this study was to evaluate the time required for various parts of the procedure to insert lumbar and sacral pedicle screws using navigation with an intraoperative, 3-dimensional imaging system. Comparison of these timings was carried out for different surgical indications. METHODS: This was a single-surgeon prospective cohort study of 69 consecutive patients (between August 2013 and June 2018) who underwent insertion of 380 pedicle screws into the lumbar and sacral vertebrae. Surgical indications, average time required for surgical exposure and attachment of the reference frame, average time required until completion of the first pedicle screw insertion, and average time required for insertion of a single pedicle screw were evaluated. RESULTS: The average time required from skin incision to reference frame attachment was 28.3 ± 20.4 (mean ± SD) minutes, and the average time required from reference frame attachment to completion of first pedicle screw insertion was 22.3 ± 9.6 minutes. The average time required for insertion of a single pedicle screw was 7.8 ± 2.7 minutes. When surgical indications were compared, the average time required for insertion of a single pedicle screw was 7.7 ± 2.6 minutes in surgery for spondylosis-related stenosis, 8.1 ± 2.8 minutes for degenerative scoliosis, and 8.2 ± 3.6 minutes for metastatic tumor (P = .89). There were no significant changes in these timings over consecutive 6-month periods. CONCLUSIONS: There is no significant learning curve and no significant difference in navigation setup and pedicle screw insertion timings with intraoperative 3-dimensional navigation systems for surgeries of different pathologies and levels of surgery. LEVEL OF EVIDENCE: 2.

The COVID-19 pandemic in Singapore: what does it mean for arthroplasty?

Background and purpose - The ongoing Coronavirus Disease-19 (COVID-19) pandemic has taken a toll on healthcare systems around the world. This has led to guidelines advising against elective procedures, which includes elective arthroplasty. Despite arthroplasty being an elective procedure, some arthroplasties are arguably essential, as pain or functional impairment maybe devastating for patients, especially during this difficult period. We describe our experience as the Division of Arthroplasty in the hospital at the epicenter of the COVID-19 pandemic in Singapore.Patients and methods - The number of COVID-19 cases reported both nationwide and at our institution from February 2020 to date were reviewed. We then collated the number of arthroplasties that we were able to cope with on a weekly basis and charted it against the number of new COVID-19 cases admitted to our institution and the prevalence of COVID-19 within the Singapore population.Results - During the COVID-19 pandemic period, a significant decrease in the volume of arthroplasties was seen. 47 arthroplasties were performed during the pandemic period from February to April, with a weekly average of 5 cases. This was a 74% reduction compared with our institutional baseline. The least number of surgeries were performed during early periods of the pandemic. This eventually rose to a maximum of 47% of our baseline numbers. Throughout this period, no cases of COVID-19 infection were reported amongst the orthopedic inpatients at our institution.Interpretation - During the early periods of the pandemic, careful planning was required to evaluate the pandemic situation and gauge our resources and manpower. Our study illustrates the number of arthroplasties that can potentially be done relative to the disease curve. This could serve as a guide to reinstating arthroplasty as the pandemic dies down. However, it is prudent to note that these situations are widely dynamic and frequent re-evaluation is required to secure patient and healthcare personnel safety, while ensuring appropriate care is delivered.

A surgeon's role in fighting a medical pandemic: Experiences from the unit at the epicentre of COVID-19 in Singapore - A cohort perspective.

IMPORTANCE: Although Singapore was one of the first countries outside of China to be affected by COVID-19, for the first 2.5 months since its first reported case on January 23, 2020, it remained one of the few nations with successful containment of spread of the pandemic with little mortality and zero intra-hospital transmissions, without instituting a major lockdown of the country. In times of an infectious epidemic where medical subspecialties lead the frontline, a surgeon's role becomes rather vague. However, the only obstacle that stands in between the surgeon and fighting in the frontline of an infectious disease outbreak, is the traditional perception of what a surgeon can do. By presenting the strategies employed by our institution and its surgical unit, which remains the epicenter of the COVID-19 fight in Singapore, together with our medical counterparts, we hope to be able to improve our practices to respond and prevent the pandemic from escalating further as a collective community of surgeons across the globe. OBSERVATIONS: Contingencies should be in place for prioritization of existing patients, triaging and treatment of suspected patients, infection control, manpower management and novel strategies for inter-disciplinary communications and education in a hospital's surgical unit during a pandemic. Working in a high risk environment with manpower and resource limitations for prolonged periods of time has effect on morale and affects surgeon burn-out. Transparent communication, avenues to address psychological needs of surgeons and leadership by example are key strategies in ensuring a sustainable fight against the pandemic. CONCLUSIONS AND RELEVANCE: With the varies strategies implemented, every surgical discipline and every surgeon should be unified and place their desire to operate aside. There should not be any differentiation between surgeon and physician, but instead, everyone has to work together as one united health care front battling the common enemy - COVID-19.

Time-sensitive ambulatory orthopaedic soft-tissue surgery paradigms during the COVID-19 pandemic.

PURPOSE: Timing of surgery for orthopaedic injuries continues to evolve, as an improved understanding of biology, healing, and technological advances continues to challenge historical norms. With the growing COVID-19 pandemic stretching limited healthcare resources, postponing surgery becomes an inevitable and unenviable task for most orthopaedic surgeons, and a shift in outpatient paradigms is required to mitigate poor outcomes in patients. METHODS: A scoping review of five databases on surgical timing and orthopaedic soft-tissue injuries was performed. All randomized controlled trials, longitudinal cohort studies, retrospective case series, systematic reviews, meta-analyses, and expert opinions were included for review, with 65 studies meeting the inclusion criteria. RESULTS: Better outcomes appear to be associated with early surgery for subluxations (< 1 week), recurrent dislocations (> 2 episodes), ligamentous and tendinous injuries (< 2 weeks), and bony avulsion injuries (< 3 weeks). Spinal conditions with neurological compromise should be operated on within 24 hours and spinal instability within 72 hours to reduce the risk of complications and poor outcomes. CONCLUSION: Most soft-tissue orthopaedic injuries can be managed with outpatient ambulatory surgery in a semi-elective setting. As the paradigm for outpatient surgery shifts due to technological advances and the COVID-19 pandemic, it is critical for surgeons to time their surgery appropriately to maintain the high standards of orthopaedic practice.

Hip hemiarthroplasty for femoral neck fractures in end-stage renal disease patients on dialysis compared to patients with late-stage chronic kidney disease.

INTRODUCTION: Hip fractures in patients with end-stage renal disease (ESRD) are associated with frequent complications and poorer outcomes. Patients on chronic dialysis are at additional risk of dialysis-related complications such as myocardial infarction and early osteolysis. We analysed the complications and implant survivorship of hemiarthroplasty in patients with femoral neck fractures with late-stage chronic kidney disease with and without pre-existing dialysis. METHODS: We conducted a retrospective case-control study of 28 patients with ESRD and 31 patients with chronic kidney disease (CKD) Stages 3-5, who had a total of 62 fractures treated with hemiarthroplasty between 2005 and 2015. The mean age of the patients was 68.33 (50.21-86.45) years. The mean follow-up time of the group was 39 months. Patient demographics, complications, outcomes and follow-up radiographs were analysed for differences. RESULTS: Patient in both groups had statistically similar demographics and comorbidity scores except for a higher incidence of hyperparathyroidism in ESRD patients on chronic dialysis (nine patients vs. zero patients; p = 0.001). These patients were more likely to develop cardiopulmonary complications in the perioperative period (odds ratio [OR] 5.04; p = 0.04) and implant loosening on radiographic analysis (OR 8.75; p = 0.02). The incidence of loosening was higher in patients with hyperparathyroidism (OR 9.80; p = 0.002). Cemented techniques, however, did not appear to be significantly associated with intraoperative fractures or loosening. CONCLUSION: Patients with ESRD on chronic dialysis were more likely to develop cardiopulmonary complications and implant loosening after hemiarthroplasty for femoral neck fractures. Hyperparathyroidism should be optimised, as it may prevent loosening. Our study did not show any difference in complications or outcomes for cemented fixation.

The judet quadricepsplasty for elderly traumatic knee extension contracture: a case report and review of the literature.

Traumatic injuries to the knee are frequently complicated by extension contractures. The Judet Quadricepsplasty allows for controlled, sequential release of extrinsic and intrinsic knee contracture components while reducing the potential for iatrogenic quadriceps rupture. We document our institutions experience with this procedure and a systematic review of the current literature. We followed up on an elderly patient with posttraumatic flexion contracture that failed conservative management and underwent Judet Quadricepsplasty. Her knee range of motion improve dramatically from 20 degrees of flexion to 100 degrees of flexion. There was a residual extension lag of 5 degrees which did not impede on the patients daily activities. A review of the literature was performed and relevant data from 12 articles was extracted. The procedure was mainly performed in young adult males in most previous studies and the range of motion improvement ranged from 51° to 110°. Wound infections were the most common complication but otherwise other complications and severe extension lag were rare. The Judet Quadricepsplasty is a useful procedure for severe extension knee contractures that has failed conservative management in all age groups of patients. It is associated with significant increases in range of motion with low rates of complication or extension lag. Diagnostic IV.

Dose-Dependent Effects of Exercise and Diet on Insulin Sensitivity and Secretion.

PURPOSE: A single bout of aerobic exercise increases insulin sensitivity the next day. The effects of exercise on insulin secretion, the role of exercise-induced energy deficit, and possible dose-response relationships are not well understood. This study aimed to evaluate insulin sensitivity and insulin secretion after progressively greater negative energy balance induced by exercise or diet. METHODS: Acute energy deficits (20% or 40% of weight maintenance needs) were induced by a single day of aerobic exercise (cycling at moderate intensity, n = 13) or dietary restriction (n = 19) in healthy men and women (age, 26 ± 2 yr; body mass index, 21.8 ± 0.5 kg·m). Intravenous glucose tolerance tests in conjunction with minimal modeling were performed the next morning, and blood samples were collected for 3 h to measure glucose and insulin concentrations. RESULTS: Insulin sensitivity increased linearly after exercise-induced energy deficits (P = 0.007) but did not change after equivalent diet-induced energy deficits (P = 0.673). Acute insulin response decreased after both exercise (P < 0.001) and dietary restriction (P = 0.005). The disposition index and glucose effectiveness were not affected by exercise (P = 0.138 and 0.808, respectively), but both decreased after 40% dietary restriction (P = 0.048 and 0.002, respectively). CONCLUSIONS: These results indicate that insulin sensitivity and insulin secretion are related to exercise energy expenditure, albeit in a different fashion (insulin sensitivity increases linearly, whereas insulin secretion drops to a nadir with a low exercise dose and does not decrease further). These changes cannot be replicated by equivalent energy deficits induced by dietary restriction, suggesting that exercise and diet have different effects on the mechanisms regulating glucose homeostasis. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03264001.

Accuracy of the α-defensin lateral flow assay for diagnosing periprosthetic joint infection in Asians.

OBJECTIVE: This study aimed to test the accuracy of the Synovasure®, α-defensin lateral flow test kit, in diagnosing periprosthetic joint infections (PJIs) in a predominantly Asian population and to evaluate whether other patient or disease factors may affect its results. METHODS: 61 Asian patients comprising 70 hip or knee prosthetic joints, performed between November 2015 and November 2018, were retrospectively evaluated. Cases were categorized as infected or not infected using Musculoskeletal Infection Society (MSIS) Criteria. Synovial fluid was tested for α-defensin using a commercially available kit. . RESULTS: The Synovasure test had a sensitivity of 73.7% (95% confidence interval (CI): 48.8-90.9%) and specificity of 92.2% (95% CI: 81.1-97.8%) in an Asian population, which was slightly lower compared to previously reported studies in a predominantly Caucasian population. The positive predictive value was 77.8% (95% CI: 56.8-90.3%) and the negative predictive value was 90.4% (95% CI: 81.5-95.2%). The test had an area under curve (AUC) of the receiver operating characteristic (ROC) graph of 0.938, which represents an accuracy that is similar to synovial white blood cells (WBCs) and almost equivalent to that of synovial polymorphonuclear cells (PMNs). The presence of diabetes ( p = 0.26), systemic inflammatory joint disease ( p = 0.33), other metallic implants ( p = 0.53), immunosuppression ( p = 0.13), prior antibiotic usage ( p = 0.99), and chronicity of symptoms ( p = 0.34) was not significantly associated with a positive test in patients with PJI. CONCLUSION: The α-defensin lateral flow test kit is highly accurate in the diagnosis of PJI but with slightly lower sensitivity and specificity in an Asian population when compared with previous studies. The test should be used in conjunction with other MSIS criteria to provide clinically relevant and meaningful results for the diagnosis of PJI.

Lipoprotein Subclass Profile after Progressive Energy Deficits Induced by Calorie Restriction or Exercise.

Weight loss, induced by chronic energy deficit, improves the blood lipid profile. However, the effects of an acute negative energy balance and the comparative efficacy of diet and exercise are not well-established. We determined the effects of progressive, acute energy deficits (20% or 40% of daily energy requirements) induced by a single day of calorie restriction (n = 19) or aerobic exercise (n = 13) in healthy subjects (age: 26 ± 9 years; body mass index (BMI): 21.8 ± 2.9 kg/m²). Fasting plasma concentrations of very low-, intermediate-, low-, and high-density lipoprotein (VLDL, LDL, IDL, and HDL, respectively) particles and their subclasses were determined using nuclear magnetic resonance. Total plasma triglyceride and VLDL-triglyceride concentrations decreased after calorie restriction and exercise (all p ≤ 0.025); the pattern of change was linear with an increasing energy deficit (all p < 0.03), with no evidence of plateauing. The number of circulating large and medium VLDL particles decreased after diet and exercise (all p < 0.015), with no change in small VLDL particles. The concentrations of IDL, LDL, and HDL particles, their relative distributions, and the particle sizes were not altered. Our data indicate that an acute negative energy balance induced by calorie restriction and aerobic exercise reduces triglyceride concentrations in a dose-dependent manner, by decreasing circulating large and medium VLDL particles.

Radial shaft fracture obliquity as a predictor of distal radioulnar joint instability.

We assessed whether radial shaft fracture obliquity measurements on radiographs could predict intra-operative distal radioulnar joint instability. We also clinically validated previously described predictors of distal radioulnar joint instability, which included a fracture line within 7.5 cm of the lunate fossa, radial shortening >5 mm, and ulna styloid fracture. We retrospectively analysed the radiographs of all surgically managed patients in our unit with radial shaft fractures from 2006 through 2016. The degree of obliquity was analysed on the basis of the maximum fracture-line angle in either the coronal or the sagittal plane. A radial shaft fracture obliquity >30° is predictive of distal radioulnar joint instability ( P = 0.001). Radial fracture shaft obliquity >30° was the most sensitive radiological parameter (76%) for predicting distal radioulnar joint instability. Oblique radial shaft fractures appear to be associated with increased incidence of distal radioulnar joint instability. This radiologic parameter may be used together with established parameters in predicting distal radioulnar joint instability for surgical treatment. LEVEL OF EVIDENCE: III.