30-day and one-year readmission rate in 11,270 patients with surgical treatment for proximal femoral fractures across Austria.

Aims: Patients with proximal femoral fractures (PFFs) are often multimorbid, thus unplanned readmissions following surgery are common. We therefore aimed to analyze 30-day and one-year readmission rates, reasons for, and factors associated with, readmission risk in a cohort of patients with surgically treated PFFs across Austria. Methods: Data from 11,270 patients with PFFs, treated surgically (osteosyntheses, n = 6,435; endoprostheses, n = 4,835) at Austrian hospitals within a one-year period (January to December 2021) was retrieved from the Leistungsorientierte Krankenanstaltenfinanzierung (Achievement-Oriented Hospital Financing). The 30-day and one-year readmission rates were reported. Readmission risk for any complication, as well as general medicine-, internal medicine-, and surgery/injury-associated complications, and factors associated with readmissions, were investigated. Results: The 30-day and one-year readmission rates due to any complication were 15% and 47%, respectively. The 30-day readmission rate (p = 0.001) was higher in endoprosthesis than osteosynthesis patients; this was not the case for the one-year readmission rate (p = 0.138). Internal medicine- (n = 2,273 (20%)) and surgery/injury-associated complications (n = 1,612 (14%)) were the most common reason for one-year readmission. Regardless of the surgical procedure, male sex was significantly associated with higher readmission risk due to any, as well as internal medicine-associated, complication. Advanced age was significantly associated with higher readmission risk after osteosynthesis. In both cohorts, treatment at mid-sized hospitals was significantly associated with lower readmission risk due to any complication, while prolonged length of stay was associated with higher one-year readmission risks due to any complication, as well as internal-medicine associated complications. Conclusion: Future health policy decisions in Austria should focus on optimization of perioperative and post-discharge management of this vulnerable patient population.

Delayed Meniscus Repair Lowers the Functional Outcome of Primary ACL Reconstruction.

BACKGROUND: Our purpose was to evaluate whether the time of intervention and the type of meniscus surgery (repair vs. partial meniscectomy) play a role in managing anterior cruciate ligament (ACL) reconstructions with concurrent meniscus pathologies. METHODS: We performed a prospective cohort study which differentiated between early and late ACL reconstructions with a cut-off at 3 months. Patients were re-evaluated after 2 years. RESULTS: Thirty-nine patients received an operation between 2-12 weeks after the injury, and thirty patients received the surgery between 13-28 weeks after trauma. The strongest negative predictive factor of the International Knee Documentation Committee subjective knee form in a hierarchical regression model was older age (ß = -0.49 per year; 95% CI [-0.91; -0.07]; p = 0.022; partial R2 = 0.08)). The strongest positive predictive factor was a higher preoperative Tegner score (ß = 3.6; 95% CI [0.13; 7.1]; p = 0.042; partial R2 = 0.07) and an interaction between meniscus repair surgery and the time of intervention (ß = 27; 95% CI [1.6; 52]; p = 0.037; partial R2 = 0.07), revealing a clinical meaningful difference as to whether meniscus repairs were performed within 12 weeks after trauma or were delayed. There was no difference whether partial meniscectomy was performed early or delayed. CONCLUSIONS: Surgical timing plays a crucial role when surgeons opt for a meniscus repair rather than for a meniscectomy.

Immunological reaction to magnesium-based implants for orthopedic applications. What do we know so far? A systematic review on in vivo studies.

Magnesium-based implants (Mg) became an attractive candidate in orthopedic surgery due to their valuable properties, such as osteoconductivity, biodegradability, elasticity and mechanical strength. However, previous studies on biodegradable and non-biodegradable metal implants showed that these materials are not inert when placed in vivo as they interact with host defensive mechanisms. The aim of this study was to systematically review available in vivo studies with Mg-based implants that investigated immunological reactions to these implants. The following questions were raised: Do different types of Mg-based implants in terms of shape, size and alloying system cause different extent of immune response? and; Are there missing links to properly understand immunological reactions upon implantation and degradation of Mg-based implants? The database used for the literature research was PubMed (U.S. National Library of Medicine) and it was undertaken in the end of 2021. The inclusion criteria comprised (i) in vivo studies with bony implantation of Mg-based implants and (ii) analysis of the presence of local immune cells or systemic inflammatory parameters. We further excluded any studies involving coated Mg-implants, in vitro studies, and studies in which the implants had no bone contact. The systematic search process was conducted according to PRISMA guidelines. Initially, the search yielded 225 original articles. After reading each article, and based on the inclusion and exclusion criteria, 16 articles were included in the systematic review. In the available studies, Mg-based implants were not found to cause any severe inflammatory reaction, and only a mild to moderate inflammatory potential was attributed to the material. The timeline of foreign body giant cell formation showed to be different between the reviewed studies. The variety of degradation kinetics of different tested implants and discrepancies in studies regarding the time points of immunological investigations impair the conclusion of immunological reactions. This may be induced by different physical properties of an implant such as size, shape and alloying system. Further research is essential to elucidate the underlying mechanisms by which implant degradation affects the immune system. Also, better understanding will facilitate the decision of patients whether to undergo surgery with new device implantation.

Long-term outcomes of surgery using the Ligament Advanced Reinforcement System as treatment for anterior cruciate ligament tears.

AIMS: The aim of this prospective study was to assess the long-term clinical, radiological, functional, and quality of life (QoL)-related outcome of patients treated with the synthetic Ligament Advanced Reinforcement System (LARS) device for anterior cruciate ligament (ACL) rupture. METHODS: A total of 41 patients who underwent ACL reconstruction with the LARS device (mean age 39.8 years (SD 12.1 ); 32% females (n = 13)) were prospectively included between August 2001 and March 2005. MRI scans and radiographs were performed at a median follow-up of 2.0 years (interquartile range (IQR) 1.3 to 3.0; n = 40) and 12.8 years (IQR 12.1 to 13.8; n = 22). Functional and QoL-related outcome was assessed in 29 patients at a median follow-up of 12.8 years (IQR 12.0 to 14.0) and clinically reconfirmed at latest median follow-up of 16.5 years (IQR 15.5 to 17.9). International Knee Documentation Committee (IKDC) and Tegner scores were obtained pre- and postoperatively, and Lysholm score postoperatively only. At latest follow-up, range of motion, knee stability tests, 36-Item Short Form Health Survey (SF-36), and IKDC scores were ascertained. Complications and reoperations during follow-up were documented. RESULTS: Cumulative complication rate was 66% (n = 27), with 11 developing within one year from surgery and 16 after one year (including five patients with both early and late complications). Ten graft failures (24%) and eight cases of reactive synovitis were observed (20%). All 11 patients with early complications and ten with late complications underwent reoperation (including five with another surgical procedure for early complications), amounting to a cumulative reoperation rate of 51% (n = 21). Revision ACL reconstruction was performed in one patient (2.4%). Median IKDC at latest follow-up was 89.7 (IQR 78.2 to 93.1), being significantly worse in the event of previous complications. Lachman test was positive in 56% (n = 15) of reconstructed knees. All norm-based SF-36 items were at or above median at latest follow-up, and did not differ depending on development of complications. CONCLUSION: Despite good functional and QoL-related results in the long term, the cumulative complication rate of 66%, including graft failures and reactive synovitis, has to be viewed with great concern. Cite this article: Bone Joint J 2022;104-B(2):242-248.

Positive effect of colors and art in patient rooms on patient recovery after total hip or knee arthroplasty : A randomized controlled trial.

BACKGROUND: Environmental stimuli and well-being are considered to be significant factors in patients' rehabilitation. The aim of this study was to describe the effect of colors and art in hospital rooms on patients' recovery after total hip or knee arthroplasty. METHODS: We performed a prospective randomized, controlled study including 80 patients. The intervention group was randomized to colored patient rooms while the control group received medical care in conventional patient rooms. Data were collected preoperatively and postoperatively (3 and 6 days after operation). We measured mood, anxiety and depression, quality of life (QOL) and pain. RESULTS: Significantly better QOL summary scores were measured in the intervention group (6 days postoperative) compared to the control group (physical component summary score 37.1 ± 5.0 vs. 34.1 ± 6.7; p = 0.029 and mental component summary score 51.6 ± 6.6 vs. 47.2 ± 8.4; p = 0.015). Postoperatively, we found decreased total mood scores in both groups showing better results for the intervention group without significant differences (p = 0.353; p = 0.711). CONCLUSION: The use of colors in hospital rooms is an effective intervention to improve well-being and to enhance faster rehabilitation. We could demonstrate a positive effect of colors on patients' postoperative QOL.

What are the Implications of Excessive Internet Searches for Medical Information by Orthopaedic Patients?

BACKGROUND: Cyberchondria may be defined as heightened distress evoked through excessive searches of the internet for medical information. In healthy people, cyberchondria is associated with a greater intolerance of uncertainty and greater health anxiety. These relationships are likely bidirectional. People who have a greater intolerance of uncertainty may be more likely to search the internet for medical information and have greater health anxiety. This greater health anxiety may lead to an increased likelihood of engaging in further internet searches and greater intolerance of uncertainty. These three constructs are important for patients because they impact patient function and health care costs. We were specifically interested in understanding the role of cyberchondria in the association between intolerance of uncertainty and health anxiety among orthopaedic patients because it has not been explored before and because knowledge about these interactions could inform treatment recommendations. QUESTIONS/PURPOSES: Does cyberchondria mediate (that is, explain) the association between intolerance of uncertainty and health anxiety in orthopaedic patients searching for medical information on the internet, after controlling for potentially confounding variables? METHODS: This was a cross-sectional study of 104 patients who had searched the internet for any medical information about their current condition. A research assistant approached 155 patients attending two orthopaedic outpatient clinics, one hand and upper extremity service and one sports medicine clinic, during a 3-month period. Ten patients declined to participate and 41 patients were excluded, predominantly because they had never searched for medical information online. The patients completed the Cyberchondria Severity Scale, Intolerance of Uncertainty Scale-short version, Short Health Anxiety Inventory, and a numerical rating scale for pain intensity at baseline, as well as demographic and clinical questionnaires. We performed a series of linear regression analyses to determine whether a greater intolerance of uncertainty predicts greater cyberchondria (mediator) and whether cyberchondria predicts greater health anxiety. Although it is more appropriate to use the language of association (such as "whether cyberchondria is associated with health anxiety") in many observational studies, here, we opted to use the language of causation because this is the conventional language for studies testing statistical mediation. RESULTS: After controlling for potentially confounding variables including pain intensity, multiple pain conditions, and education, cyberchondria explained 33% of the variance of the effect of intolerance of uncertainty on health anxiety (95% CI, 6.98 to 114.72%; p < 0.001). CONCLUSIONS: Among orthopaedic patients who search the internet for medical information, a greater intolerance of uncertainty is associated with greater cyberchondria, which is associated with greater anxiety about health. Identifying patients with an intolerance of uncertainty and educating them about the negative role of compulsive searches for medical information may improve the success of orthopaedic treatment. Orthopaedic surgeons should also consider making referrals for cognitive behavioral therapy in these instances to increase the patient's tolerance of uncertainty, decrease internet searching habits, and reduce anxiety about health. LEVEL OF EVIDENCE: Level III, prognostic study.

What Is the Relationship of Fear Avoidance to Physical Function and Pain Intensity in Injured Athletes?

BACKGROUND: Fear avoidance can play a prominent role in maladaptive responses to an injury. In injured athletes, such pain-related fear or fear avoidance behavior may have a substantial influence on the recovery process. Specifically, it may explain why some are able to reach their preinjury abilities, whereas others are unable to return to sport. QUESTIONS/PURPOSES: (1) Is fear avoidance in athletes associated with decreased physical function after injury? (2) To what degree is fear avoidance associated with athletes' pain intensity? METHODS: In a cross-sectional study, we recruited injured athletes-defined as patients with sports-related injury, weekly engagement in sport activities, participation in competitive events as part of a team or club, self-identification as an athlete, and a desire to return to sport after recovery-from an orthopaedic sports medicine center at a major urban university hospital. Of 130 approached patients, 102 (84% men; mean ± SD age 25 ± 8.5 years) met the inclusion criteria. Participants completed a demographic questionnaire, the Athlete Fear Avoidance Questionnaire, which assesses injury-related fear and avoidance behavior specifically in an athletic population, the Pain Catastrophizing Scale, the Hospital Anxiety and Depression Scale, and two Patient-Reported Outcomes Measurement Information System measures: Physical Function Computerized Adaptive Testing (CAT) and Pain Intensity CAT. RESULTS: After controlling for age, injury region (upper versus lower extremity), catastrophic thinking, and emotional distress, we found that an increase in athletes' fear avoidance was associated with a decrease in physical function (b = -0.32; p = 0.002). The model explained 30% of the variation in physical function with 7.3% explained uniquely by fear avoidance. After controlling for initial appointment/followup, surgery for the current condition, multiple pain conditions, history of prior sport-related injury/surgery, pain medication prescription, catastrophic thinking, and emotional distress, athletes' fear avoidance was not associated with pain (b = -0.14; p = 0.249). The model explained 40% of the variation in pain intensity and pain catastrophizing (b = 0.30; p = 0.001) uniquely explained 7.1% of this variation. CONCLUSIONS: In injured athletes, fear avoidance is independently associated with decreased physical function, whereas pain catastrophizing is associated with high pain intensity. Both level of an athlete's fear avoidance and catastrophic thinking about pain should be accounted for in clinical interventions aimed at helping athletes improve recovery and return to sport. LEVEL OF EVIDENCE: Level II, prognostic study.

Ulnar Neck Fractures Associated with Distal Radius Fractures.

Background There is little published data to guide management of ulnar neck fractures associated with fractures of the distal radius. Purpose As unplanned surgery usually reflects adverse events and this injury combination is relatively uncommon, we used a large database to study the incidence of unplanned surgeries after surgical and nonsurgical treatment of distal metaphyseal ulna fractures associated with a distal radius fracture and identify factors associated with these unplanned surgeries. Patients and Methods We identified 277 patients with an ulnar neck fracture associated with a distal radius fracture. Fifty-six (20%) ulnar neck fractures were initially treated operatively and six of them (11%) had a second, unplanned surgery. Of the 221 initially nonoperatively treated fractures, only one (0.45%) had a subsequent unplanned surgery that seemed unrelated to the fracture (ulnar nerve neurolysis). Results Bivariate analysis showed that younger age, open fracture, multifragmentary fractures, and initial operative treatment of the ulnar neck fracture were significantly associated with unplanned surgery. A multivariable analysis was not feasible due to the small number of unplanned surgeries. Conclusion Eighty percent of ulnar neck fractures associated with a fracture of the distal radius was treated nonoperatively in our region, and subsequent surgery for problems was very uncommon. Operative treatment and fracture complexity were associated with unplanned surgery, which reflected some measure of injury severity, technical inadequacy, and inherent problems associated with surgery. Level of Evidence Level II, prognostic study.

Pain anxiety differentially mediates the association of pain intensity with function depending on level of intolerance of uncertainty.

Uncertainty about symptom duration, cause, prognosis and treatment is common in patients who seek medical care, yet individual ability to manage this uncertainty varies. Intolerance of uncertainty is considered an important factor in the etiology and persistence of negative emotions- in particular, depression and anxiety. We explored the contribution of intolerance of uncertainty to anxiety due to pain and physical function in patients seeking care at an orthopedic medical practice. Participants (N = 105, mean age of 51 ± 17, 63% male) were administered PROMIS Physical Function v1.2 Upper Extremity CAT, Numerical Rating Scale (NRS), Pain Anxiety Symptoms Scale-short form (PASS-20), and the Intolerance of Uncertainty Scale-short version (IUS-12). Results showed that the mediating role of pain anxiety is contingent upon the level of intolerance of uncertainty. Specifically, a minimum level of intolerance of uncertainty is required for the development of pain anxiety and its effect on function, and as intolerance of uncertainty rises from low to medium to high levels, the effect of pain on function goes from being independent of the anxiety to being more and more carried by and through anxiety about pain. These findings support the contention that intolerance of uncertainty plays a crucial role in the relationship between pain, pain anxiety, and physical function. Intolerance of uncertainty appears to be a trans-diagnostic target for coping skills training.

Bidirectional mediation of depression and pain intensity on their associations with upper extremity physical function.

Pain intensity and symptoms of depression are correlated and individually associated with decreased physical function. We compared two explanatory mediation models; one with depression as mediator of the association of pain intensity with physical function and the other one with pain intensity as the mediator of the effect of depression on physical function. In a cross-sectional study, 102 patients with upper extremity musculoskeletal illness completed measures of pain intensity, PROMIS depression CAT, PROMIS physical function-upper extremity CAT and demographics. We determined that pain intensity and symptoms of depression were partial mediators of their respective and independent effects on physical function. While depression had a larger standardized mediation effect and a bigger kappa-squared (κ 2) effect size compared to pain intensity, the actual proportion of variance in physical function that could be explained by the mediated effects (i.e., R 2 mediation effect size) was equal in both models suggesting that the two mediation models have equal ability to explain variations in physical function. The bidirectional mediation effect suggests a reinforcement mechanism, in which, pain intensity and symptoms of depression reciprocally influence their negative impacts on physical function among patients with musculoskeletal illness.

Type D personality in patients with upper extremity musculoskeletal illness: Internal consistency, structural validity and relationship to pain interference.

OBJECTIVE: Type D personality - the joint tendency toward negative affectivity (NA) and social inhibition (SI) - is associated with greater symptom perception and negative health outcomes among various patient populations. We investigated Type D personality among patients with upper extremity musculoskeletal illness. METHOD: In cross-sectional design, we estimated the prevalence of Type D personality in this population and explored the associations of two different Type D conceptualizations (i.e., categorical and dimensional as the NA×SI interaction) and the individual NA and SI traits with pain interference as well as structural-internal validity of DS14. RESULTS: The categorical Type D personality and greater NA and SI were associated with pain interference above and beyond descriptive variables, but the interaction term between NA and SI was not. NA explained a larger proportion of the variance in pain interference than SI. DS14 showed a two-factor structure and high internal consistency in this sample. CONCLUSIONS: The categorical Type D allows for identifying individuals who struggle with recovery from musculoskeletal injury. Although the dimensional conceptualization didn't prove to be associated with pain interference, NA and SI appear to have individual effects on pain interference, with most variance being accounted for by NA. Implications for clinical care are discussed.

Emotion regulation strategies mediate the associations of positive and negative affect to upper extremity physical function.

BACKGROUND: The Gross process model of emotion regulation holds that emotion-eliciting situations (e.g. musculoskeletal illness) can be strategically regulated to determine the final emotional and behavioral response. Also, there is some evidence that innate emotional traits may predispose an individual to a particular regulating coping style. METHODS: We enrolled 107 patients with upper extremity musculoskeletal illness in this cross-sectional study. They completed self-report measures of positive and negative affect, emotion regulation strategies (cognitive reappraisal and expressive suppression), upper extremity physical function, pain intensity, and demographics. We used Preacher and Hayes' bootstrapping approach to process analysis to infer the direct effect of positive and negative affect on physical function as well as their indirect effects through activation of emotion regulation strategies. RESULTS: Negative affect was associated with decreased physical function. The association was partly mediated by expressive suppression (b (SE)=-.10 (.05), 95% BCa CI [-.21, -.02]). Positive affect was associated with increased physical function. Cognitive reappraisal partially mediated this association (b (SE)=.11 (.05), 95% BCa CI [.03, .24]). After controlling for pain intensity, the ratio of the mediated effect to total effect grew even larger in controlled model comparing to uncontrolled model (33% vs. 26% for expressive suppression and 32% vs. 30% for cognitive reappraisal). CONCLUSIONS: The relationships between affect, emotion regulation strategies and physical function appear to be more dependent on the emotional response to an orthopedic condition rather than the intensity of the nociceptive stimulation of the pain. Findings support integration of emotion regulation training in skill-based psychotherapy in this population to mitigate the effect of negative affect and enhance the influence of positive affect on physical function.

Pain Catastrophizing Mediates the Effect of Psychological Inflexibility on Pain Intensity and Upper Extremity Physical Function in Patients with Upper Extremity Illness.

BACKGROUND: Psychological inflexibility-the inability to take value-based actions in the presence of unwanted thoughts, feelings, or bodily symptoms-is associated with negative health outcomes including depression and anxiety. OBJECTIVE: We aimed to determine the association between the general construct of psychological inflexibility and pain intensity, and upper extremity physical function in patients with musculoskeletal illness in an orthopedics practice. We also set out to test multiple-mediator models proposing that psychological inflexibility affects pain intensity and upper extremity physical function directly, as well as indirectly through depression, anxiety, and pain catastrophizing. METHODS: One hundred and eight patients with upper extremity illness completed self-report measures of pain intensity, upper extremity physical function, psychological inflexibility, pain catastrophizing, depression, and anxiety in this cross-sectional study. RESULTS: We found that psychological inflexibility affected pain intensity and upper extremity physical function directly and indirectly. Pain catastrophizing but not depression or anxiety mediated the association of psychological inflexibility to pain intensity and upper extremity physical function. CONCLUSIONS: Psychological inflexibility plays an important role in understanding the increased pain and decreased upper extremity physical function in patients with musculoskeletal pain. It also suggests that the cognitive error of pain catastrophizing is one of the mechanisms through which the general construct of psychological inflexibility may influence pain intensity and upper extremity physical function. Psychological treatments aimed at decreasing pain and increasing upper extremity physical function should target both pain catastrophizing and psychological inflexibility.

Magnesium alloys for temporary implants in osteosynthesis: in vivo studies of their degradation and interaction with bone.

This study investigates the bone and tissue response to degrading magnesium pin implants in the growing rat skeleton by continuous in vivo microfocus computed tomography (µCT) monitoring over the entire pin degradation period, with special focus on bone remodeling after implant dissolution. The influence of gas release on tissue performance upon degradation of the magnesium implant is also addressed. Two different magnesium alloys - one fast degrading (ZX50) and one slowly degrading (WZ21) - were used for evaluating the bone response in 32 male Sprague-Dawley rats. After femoral pin implantation µCTs were performed every 4 weeks over the 24 weeks of the study period. ZX50 pins exhibited early degradation and released large hydrogen gas volumes. While considerable callus formation occurred, the bone function was not permanently harmed and the bone recovered unexpectedly quickly after complete pin degradation. WZ21 pins kept their integrity for more than 4 weeks and showed good osteoconductive properties by enhancing bone accumulation at the pin surface. Despite excessive gas formation, the magnesium pins did not harm bone regeneration. At smaller degradation rates, gas evolution remained unproblematic and the magnesium implants showed good biocompatibility. Online µCT monitoring is shown to be suitable for evaluating materials degradation and bone response in vivo, providing continuous information on the implant and tissue performance in the same living animal.

PHB, crystalline and amorphous magnesium alloys: promising candidates for bioresorbable osteosynthesis implants?

In this study various biodegradable materials were tested for their suitability for use in osteosynthesis implants, in particular as elastically stable intramedullary nails for fracture treatment in paediatric orthopaedics. The materials investigated comprise polyhydroxybutyrate (PHB), which belongs to the polyester family and is produced by microorganisms, with additions of ZrO2 and a bone graft substitute; two crystalline magnesium alloys with significantly different degradation rates ZX50 (MgZnCa, fast) and WZ21 (MgYZnCa, slow); and MgZnCa bulk metallic glasses (BMG). Push-out tests were conducted after various implantation times in rat femur meta-diaphysis to evaluate the shear forces between the implant material and the bone. The most promising materials are WZ21 and BMG, which exhibit high shear forces and push-out energies. The degradation rate of ZX50 is too fast and thus the alloy does not maintain its mechanical stability long enough during the fracture-healing period. PHB exhibits insufficient mechanical properties: it degrades very slowly and the respective low shear forces and push-out energy levels are unsatisfactory.