Limb position affects intraoperative assessment of condylar width.

PURPOSE: We sought to define how changes in position and rotation of fluoroscopic imaging may affect the assessment of condylar widening intraoperatively. METHODS: Thirty-three patients with tibial plateau fractures were prospectively identified and included in this study. Fluoroscopic images of the uninjured tibial plateau were obtained in (1) full extension and (2) slight flexion on foam ramp. Beginning with a plateau view, additional views of the tibial plateau were then obtained by rotating the fluoroscope around the knee in 5 degree increments up to 15 degrees in both internal and external rotation. Measurements of distal femoral condylar width (DFW), distal femoral articular width (FAW), proximal tibial articular width (TAW) and lateral plateau width (LPW) were performed. RESULTS: LPW was decreased in flexion compared to extension at all degrees of rotation (p = 0.04-0.00001). There was a trend toward increasing LPW with increasing degrees of internal rotation which reached significance at 15˚ of internal rotation when the knee was flexed. On ANOVA, there was a significant difference of LPW with increasing degree of internal rotation when the knee was in flexion (p = 0.008), but not in extension. There were no differences in DFW, FAW, TAW and DFW/TAW at any point though LPW was decreased in flexion at all degrees of rotation. The FAW/TAW ratio was increased in flexion at all degrees of rotation. DISCUSSION: The knee in flexion will underestimate the measurement of condylar width compared to the knee in full extension, by ~ 2 mm. Rotation of the knee, in comparison, did not have a significant effect on condylar width assessment. LEVEL OF EVIDENCE: Diagnostic II.

Characterizing Leadership Trends in Hand Surgery Fellowship Programs.

Purpose: The purpose of this study was to characterize academic and demographic factors most associated with fellowship director (FD) roles in hand surgery programs. A secondary aim was to characterize educational and employment trends. The final aim was to compare these findings with those in other orthopedic subspecialties. Methods: Domestic programs were identified using the American Society for Surgery of the Hand fellowship directory. Data were collected via internet searches of publicly available information and direct contact with programs. Variables included demographic characteristics (age, sex, and race/ethnicity), education and employment history, Hirsch index (H-index) research productivity, and membership of select hand surgery societies. Results: Information about 86 FDs was collected from a total of 88 identified hand surgery fellowships. Seventy-six (88.4%) FDs were men, whereas 10 (11.6%) were women. The mean age was 53.3 years. Most FDs (n = 68, 79.1%) completed their residency in orthopedic surgery. The average Scopus H-index was 16.3. Most FDs were White (n = 64, 74%) followed by Asian (n = 14, 16%). The mean duration from fellowship completion to FD appointment was 12.6 years, whereas the mean duration of employment at an institution before FD appointment was 17.9 years. The mean duration of tenure as an FD was 9.8 years. Twenty-eight (32.94%) individuals served as an FD at their residency institution and 20 (23.5%) led at their fellowship institution. The most frequently attended residency institution by FDs was University of Pennsylvania, whereas Mayo Clinic was the most frequently attended fellowship program. Six FDs have served as the presidents of a hand surgery society. Conclusions: Fellowship directors are largely White and men. They are distinguished by their research productivity. A few select programs contribute an outsized proportion of individuals to FD positions. This may be due to a pipeline effect or because applicants with ambition to become FDs pursue specific programs for training. Clinical relevance: This study characterizes the academic/demographic factors of hand surgery FDs.

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

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

Outcomes in Pediatric Hip FAI Surgery: a Scoping Review.

PURPOSE OF REVIEW: Femoracetabular impingement (FAI) is a common source of hip pain in children and adolescents. While nonoperative therapies and open surgical procedures can be effective, hip arthroscopy is a minimally invasive treatment option with substantial benefit. The purpose of this paper is to evaluate the current role of hip arthroscopy in treating FAI within the pediatric population. This article examines its efficacy through a review of hip arthroscopy outcomes in the contemporary orthopaedic literature. RECENT FINDINGS: Morphologic changes in the acetabulum and proximal femur seen in FAI can be attributed to a multitude of etiologies-including idiopathic FAI, Legg-Calve-Perthes, and slipped capital femoral epiphysis. In general, arthroscopic treatment of FAI secondary to these conditions leads to statistically significant improvements in pain and patient-reported outcomes in the short and long term. In the pediatric athlete, repetitive stress on the hip perpetuates FAI and can drastically hinder performance. Hip arthroscopy allows for a high rate of return to sport with minimal morbidity in this population. Overall, pediatric hip arthroscopy is effective in treating FAI secondary to a wide variety of conditions. Despite its clinical benefits, patients and their families should be counseled regarding alternative treatments, potential complications, and return to play.

Increased 30-Day Postoperative Readmission and Medical Complication Rates Among Patients 65 Years and Older Following Arthroscopic Rotator Cuff Repair.

Purpose: The purpose of this study is to use a large national database to assess short-term adverse events following arthroscopic rotator cuff repair in patients 65 years and older. Methods: The ACS NSQIP database was queried to identify patients that underwent arthroscopic rotator cuff repair between December 31, 2015, and January 1, 2017. Patients were split into two groups: 1) between 40-65 years old and 2) 65+ years old. Cases involving open rotator cuff repair, total shoulder arthroplasty, hemiarthroplasty, and emergency surgery were excluded. Exact matching was used to control for confounding variables, including sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, operative time, and several medical comorbidities. After matching, the incidence of several 30-day patient complication measures was compared between the groups. Binary logistic regression was used to identify covariates associated with various 30-day complications. Results: A total of 17,880 patients were included in the study. 69.4% (n = 12,404) patients were between 40 and 65 years old and 30.6% (n = 5,476) patients were 65+ years old. After matching, 9,210 patients were included in the final analysis. After matching, patients 65 years and older were more likely to experience 30-day unplanned readmission (P = .035) and overall medical complications (P = .036). There were no significant differences in most 30-day complication measures, including mortality (P = .250), reoperation (P = .449), non-home discharge (P = .255), surgical complications (P = .146), and several medical complications, including myocardial infarction (P = .165), deep venous thromboembolism (P = .206), pulmonary embolism (P = .196), and cerebrovascular accident (P > .999) between the two age groups. Conclusions: In this matched cohort study, patients 65 years and older experienced a higher rate of 30-day unplanned readmission and overall medical complications following elective arthroscopic rotator cuff repair relative to patients under 65. However, these older patients did not have significantly worse rates of other 30-day complication measures, including mortality, reoperation, return to the OR, and non-home discharge.

Survey Analysis of Orthopedic Call Compensation.

We sought to determine the type, frequency, and compensation details of orthopedic call for orthopedic traumatologists. We administered a 24-question survey to all members of the Orthopaedic Trauma Association regarding the number and type of orthopedic surgeons within the call pool, frequency of call, number of hospitals covered, and compensation for weekday, weekend, holiday, and pediatric calls. A total of 105 orthopedic surgeons replied. The most common number of physicians in the call pool was 6 to 10 (42.9%), whereas the most common number of traumatologists was 0 to 5 (90.5%), with 71.4% taking call at 1 hospital. Further, 56.7% were paid separately for weekday trauma call, with the most common number of call days per week being 2. The most common compensation was $1001 to $1500 (31.6%). For weekend call, 49.5% of physicians were paid separately, with the most common number of weekends on call per year being 11 to 15 (34.3% of replies). For pediatric call, 54.3% of physicians took call, with 28.6% paid separately and 33.3% receiving $0 to $500. For holiday call, 40.2% of physicians were paid separately, with 30.8% receiving $1001 to $1500. We describe the characteristics of traumatology call. Approximately 50% of physicians (range, 28.6%-56.3%) are compensated separately for taking different forms of call (ie, weekday, weekend, holiday). [Orthopedics. 2022;45(5):293-296.].

Treatment of tibial plateau fractures with a novel fenestrated screw system for delivery of bone graft substitute.

PURPOSE: The purpose of this study was to describe the incidence of subsidence in patients with AO/OTA 41 (tibial plateau) fractures which were repaired with a novel fenestrated screw system to used to deliver CaPO4 bone substitute material to fill the subchondral void and support the articular reduction. METHODS: Patients with unicondylar and bicondylar tibial plateau fractures were treated according to the usual technique of two surgeons. After fixation, the Zimmer Biomet N-Force Fixation System®, a fenestrated screw that allows for the injection of bone substitute was placed and used for injection of the proprietary calcium phosphate bone graft substitute into the subchondral void. For all included patients, demographic information, operative data, radiographs, and clinic notes were reviewed. Patients were considered to have articular subsidence if one or more of two observations were made when comparing post-operative to their most recent clinic radiographs: > 2 mm change in the distance between the screw and the lowest point of the tibial plateau, > 2 mm change in the distance between the screw and the most superior aspect of the plate. Data were analyzed to determine if there were any identifiable risk factors for complication, reoperation, or subsidence using logistic regression. Statistical significance was set at p < 0.05. RESULTS: 34 patients were included with an average follow-up of 32.03 ± 22.52 weeks. There were no overall differences between height relative to the medial plateau or the plate. Two patients (5.9%) had articular subsidence. Six patients (15.2%) underwent reoperation, two (6%) for manipulations under anaesthesia due to arthrofibrosis, and four (12%) due to infections. There were 6 (19%) total infections as 2 were superficial and required solely antibiotics. One patient had early failure. CONCLUSION: Use of a novel fenestrated screw system for the delivery of CaPO4 BSM results in articular subsidence and complication rates similar to previously published values and appears to be a viable option for addressing subchondral defects in tibial plateau fractures. LEVEL OF EVIDENCE: IV.

Ballistic trauma patients have decreased early narcotic demand relative to blunt trauma patients: Blunt ballistic injury opioid use.

OBJECTIVES: Blunt and ballistic injuries are two common injury mechanisms encountered by orthopaedic traumatologists. However the intrinsic nature of these injures may necessitate differences in operative and post-operative care. Given the evolving opioid crisis in the medical community, considerable attention has been given to appropriate management of pain; particularly in orthopaedic patients. We sought to evaluate relative postoperative narcotic use in blunt injuries and ballistic injuries. DESIGN: Retrospective Cohort Study. SETTING: Academic Level-1 Trauma Center. PATIENTS: 96 Patients with blunt or ballistic fractures. INTERVENTION: Inpatient narcotic pain management after orthopaedic fracture management. MAIN OUTCOME MEASUREMENTS: Morphine equivalent units (MEU). RESULTS: Patients with blunt injuries had a higher MEU compared to ballistic injuries in the first 24 hours postoperatively (35.0 vs 29.5 MEU, p=0.02). There were no differences in opiate consumption 24-48 hours (34.8 vs 28.0 MEU), 48 hours - 7 days post op (28.4 vs 30.4 MEU) or the 24 hours before discharge (30.0 vs 28.6 MEU). On multivariate analysis, during the 24-48 hours and 24 hours before discharge timepoints total EBL was associated with increased opioid usage. During days 3-7 (p<0.001) and in the final 24 hours prior to discharge (p=0.012), the number of orthopaedic procedures was a predictor of opioid consumption. CONCLUSION: Blunt injuries required an increased postoperative narcotic consumption during the first 24 hours of inpatient stay following orthopedic fracture fixation. However, there was no difference at other time points. Immediate post-operative pain regimens may be decreased for patients with ballistic injuries. LEVEL OF EVIDENCE: III.

A Survey to Assess Agreement Between Pelvic Surgeons on the Outcome of Examination Under Anesthesia for Lateral Compression Pelvic Fractures.

OBJECTIVES: To assess agreement among pelvic surgeons regarding the interpretation of examination under anesthesia (EUA), the methodology by which EUA should be performed, and the definition of a positive examination. DESIGN: Survey. PATIENTS/PARTICIPANTS: Ten patients who presented to our Level 1 trauma center with a pelvic ring injury were selected as clinical vignettes. Vignettes were distributed to 15 experienced pelvic surgeons. INTERVENTION: Examination under anesthesia. MAIN OUTCOME MEASUREMENTS: Agreement regarding pelvic fracture stability (defined as >80% similar responses), need for surgical fixation, definition of an unstable EUA, and method of performing EUA. RESULTS: There was agreement that a pelvic fracture was stable or unstable in 8 (80%) of 10 cases. There was agreement that fixation was required or not required in 6 (60.0%) of 10 cases. Seven (46.7%) surgeons endorsed performing a full 15-part EUA, whereas the other 8 (53.3%) used an abbreviated or alternative method. Eight (53.3%) surgeons provided a definition of what constitutes a positive EUA, whereas the remaining 7 did not endorse adhering to a strict definition. CONCLUSIONS: Pelvic surgeons generally agree on what constitutes a positive or negative EUA but not necessarily the implications of a positive or negative examination. There is no clear consensus among surgeons regarding the method of performing EUA nor regarding the definition of a positive EUA. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effect of bariatric surgery on outcomes in the operative treatment of hip fractures.

INTRODUCTION: Few studies have evaluated the effect of prior bariatric surgery on outcomes following the operative treatment of hip fractures. The purpose of this study is to evaluate these metrics in a population of bariatric surgery patients compared to a control group who were operatively treated for hip fractures. MATERIALS AND METHODS: The California Office of Statewide Health Planning & Development (OSHPD) discharge database was accessed to identify patients who sustained a hip fracture between 2000-2014. CPT codes were utilized to identify patients who had a prior history of bariatric surgery within this time period. A control cohort of patients who had undergone previous appendectomy were queried similarly. The study evaluated complication rates and inpatient mortality at 30- and 90-days postoperatively as well as 30- and 90-day readmission rates. RESULTS: There were 1,327 bariatric and 2,127 control patients identified. Survival rates were significantly lower in bariatric patients compared to controls (87.2% vs. 91.8%, p = 0.048) at 5 years. After controlling for confounders, bariatric patients had higher 30- (OR 1.46, p = 0.005) and 90-day (OR 1.38, p = 0.011) readmission rates. There were no differences in all-cause complication and inpatient mortality rates between groups at 30 or 90 days. DISCUSSION: Bariatric surgery patients are at increased risk of readmission after hip fracture surgery. Further research is warranted to delineate potential risk factors and mitigate readmission in these patients. LEVEL OF EVIDENCE: III.

Characteristics of Marijuana Use Among Orthopedic Patients.

Marijuana use among orthopedic patients has not been extensively studied. The purpose of this study was to investigate the prevalence of marijuana use among orthopedic surgery patients. Additionally, the authors sought to better characterize how and why their patients use marijuana. Patients presenting at 3 institutions in 2 states for orthopedic surgery were asked to complete a voluntary survey. In addition to basic demographic information, the survey contained questions regarding the frequency of, methods of, and reasons for marijuana use. Patients who had used marijuana in the past year were categorized as marijuana users. A total of 275 patients completed surveys, of whom 94 (34%) endorsed marijuana use in the past year. A majority of marijuana users (55%) endorsed using marijuana either daily or weekly. Smoking was the most common means of marijuana use (90%), followed by edible products (35%) and vaporizing (24%). Pain management (54%) and recreation (52%) were the most commonly cited reasons for using marijuana. Eighty-six percent of marijuana users indicated that they would stop using marijuana if told by their physician that marijuana use would adversely affect their surgery. Marijuana use is common among orthopedic patients. Many patients believe marijuana is beneficial for managing pain and other medical conditions, although most would be willing to stop using marijuana if told it would negatively impact their surgery. Further study into the effects of marijuana use on musculoskeletal health is warranted because marijuana use may be a risk factor easily modified to improve surgical outcomes. [Orthopedics. 2020; 43(2): 108-112.].

Exploratory Study of Heart Rate Variability and Sleep among Emergency Medical Services Shift Workers.

OBJECTIVES: To characterize the continuity and duration of sleep, and to measure nocturnal cardiac autonomic balance via heart rate variability (HRV) in a group of emergency medical technicians (EMTs) on and off duty. METHODS: Fourteen EMTs completed an online, daily sleep log that recorded total sleep duration, bedtime, rise time, and the number of alarms that caused awakening. HRV was captured using a physiological status monitor (PSM) affixed to a chest strap during sleep. RESULTS: For the 7-day trial, each of the 14 EMTs logged three work days (WDs) and four non-work days (NWDs). They reported sleeping significantly fewer hours per night on WDs (6.4 ± 2.1) than on NWDs (7.9 ± 0.5; P < 0.05), and experienced more sleep disruptions on WDs (4.4 ± 2.8) than on NWDs (1.3 ± 2.2; P < 0.001) as measured by the number of alarms. Global and vagal indices of HRV during sleep were significantly reduced during WDs (Standard Deviation of Normal R-R Intervals (SDNN) = 43.4 ± 2.0 ms and High Frequency (HF) = 24.3 ± 1.2 ms2) when compared to NWDs (SDNN = 61.1 ± 1.0 ms and HF = 42.7 ± 1.5 ms2; P < 0.001). CONCLUSION: EMTs who worked 24-hour shifts had shorter, more fragmented sleep associated with greater cumulative exposure to increased sympathetic and decreased parasympathetic activity as measured via sleep HRV. These changes in cardiac autonomic tone constitute one plausible pathway through which sleep deprivation may increase risk for cardiovascular disease.

Scalable modulator for frequency shift keying in free space optical communications.

Frequency shift keyed (FSK) modulation formats are well-suited to deep space links and other high loss links. FSK's advantage comes from its use of bandwidth expansion. I.e., FSK counteracts power losses in the link by using an optical bandwidth that is greater than the data rate, just as pulse position modulation (PPM) does. Unlike PPM, increasing FSK's bandwidth expansion does not require increased bandwidth in electronic components. We present an FSK modulator whose component count rises logarithmically with the bandwidth expansion. We tested it with four-fold bandwidth expansion at 5 and 20 Gbit/s. When paired with a pre-amplified receiver, the required received power was about 4 and 5 dB from the theoretical best for such receivers. We also tested the FSK transmitter with a photon counting receiver.

781 Mbit/s photon-counting optical communications using a superconducting nanowire detector.

We demonstrate 1550 nm photon-counting optical communications with a NbN-nanowire superconducting single-photon detector. Source data are encoded with a rate-1/2 forward-error correcting code and transmitted by use of 32-ary pulse-position modulation at 5 and 10 GHz slot rates. Error-free performance is obtained with -0.5 detected photon per source bit at a source data rate of 781 Mbits/s. To the best of our knowledge, this is the highest reported data rate for a photon-counting receiver.