Risk Factors for Leaving Against Medical Advice in Patients Admitted for Upper Extremity Orthopedic Procedures.

INTRODUCTION: Patients who leave against medical advice (AMA) face increased risks of negative health outcomes, presenting a challenge for healthcare systems. This study examines demographic and hospital course factors associated with patients leaving AMA after an upper extremity (UE) orthopaedic procedure. METHODS: We analyzed 262,912 patients who underwent UE orthopaedic procedures between 2011 and 2020, using the Healthcare Cost and Utilization Project database. We then compared demographic and hospital course factors between patients who left AMA and those who did not leave AMA. RESULTS: Of 262,912 UE orthopaedic patients, 0.45% (1,173) left AMA. Those more likely to leave AMA were aged 30 to 49 (OR, 5.953, P < 0.001), Black (OR, 1.708, P < 0.001), had Medicaid (OR, 3.436, P < 0.001), and were in the 1st to 25th income percentile (OR, 1.657, P < 0.001). Female patients were less likely to leave AMA than male patients (OR, 0.647, P < 0.001). Patients leaving AMA had longer stays (3.626 versus 2.363 days, P < 0.001) and longer recovery times (2.733 versus 1.977, P < 0.001). CONCLUSION: We found that male, Black, younger than 49 years old, Medicaid-insured, and lowest income quartile patients are more likely to leave AMA after UE orthopaedic treatment.

Effective Risk Assessment for Distal Radius Fractures: A Rigorous Multivariable Regression Analysis, Using a Novel 8-Item Modified Frailty Index.

Introduction Distal radius fractures (DRFs) are among the most common orthopaedic injuries. The prevalence of DRFs is increasing across all age groups but remains the second most common fracture in the elderly. The modified frailty index (MFI) often predicts morbidity and mortality in orthopaedic injuries. This study aims to determine the predictive value of MFI on complication rates following DRF and the patient length of stay and discharge outcomes. Methods We utilized our MFI to perform a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database. Results In a total of 22,313 patients, the average age was 46 ± 16. An increase in MFI led to an increase in the odds ratio of readmission and reoperation ( p < 0.001). MFI predicted complications, doubling the rate as the score increased from 1 to 2 ( p < 0.001). An MFI of 2 also led to a delayed hospital stay of 5 days ( p < 0.001), as well as an increase in the odds of patients not being sent home at discharge ( p < 0.001). Finally, life-threatening complications were also predicted with an increased MFI, the odds of a life-threatening complication increasing 488.20 times at an MFI of 3 ( p < 0.001). Discussion and Conclusion While surgical decision-making for frail patients with DRFs remains contentious, this novel 8-item MFI score was significantly associated with the probability of hospital readmission/reoperation, postoperative complications, and delayed hospital length of stay. Three new parameters were incorporated into our 8-item score compared with the conventional 5; hypoalbuminemia status (< 3.5 mg/dL), previous diagnosis of osteoporosis, and severe obesity (body mass index > 35) enhancing its sensitivity. Future studies are warranted for its prospective utility in ruling out postsurgical comorbidity.

Management of gunshot wounds near the elbow: experiences at a high-volume level I trauma center.

BACKGROUND: Gunshot-related fractures near the elbow are challenging, and available data to guide the practitioner are lacking. This report analyzes injury patterns and treatment strategies in a case series from a high-volume urban trauma center. METHODS: All periarticular gunshot fractures near the elbow treated at a level 1 trauma center from 2014 to 2018 were retrospectively reviewed. Fracture location, patient demographics, concomitant injuries, treatment modalities, and complications were analyzed. RESULTS: Twenty-four patients were identified. All patients received prophylactic antibiotics upon admission and underwent urgent surgical debridement. Open reduction and internal fixation (ORIF) was performed with initial debridement in 22 of 24 patients. Seven patients sustained distal humerus fractures, 10 patients sustained isolated proximal ulna or proximal radius fractures, and seven had combined fracture patterns. Eleven patients presented with nerve palsy, and two had transected nerves. Two patients had vascular injury requiring repair. One patient required a temporary elbow-spanning external fixator and underwent staged debridement followed by ORIF. One patient with a grade IIIC fracture developed a deep infection that precluded ORIF. One patient required revision ORIF due to fracture displacement. CONCLUSIONS: This investigation reports on management of ballistic fractures near the elbow at a busy urban level I trauma center. Our management centered on rapid debridement, early definitive fixation, and intravenous antibiotic administration. We report on associated neurovascular injury, bone loss, and other challenges in this patient population. Level of evidence: IV.

Infectious profiles in civilian gunshot associated long bone fractures.

PURPOSE: There is a paucity of literature on infections in civilian gunshot associated with long bone fractures with the reported rates ranging from 0-15.7%.This study aimed to investigate the rates of infection associated with long bone fractures caused by civilian gunshots. The specific objectives were to determine if certain extremities were at a higher risk for infection and to identify the types of bacteria present in these infections by analyzing culture isolates. METHODS: We conducted a retrospective review of consecutive patients aged 18-64 who sustained gunshot-associated long bone fractures at an urban Level I trauma centre from 2010 to 2017. Patient selection was based done through a institutional trauma centre database using international classification of diseases (ICD) 9 and 10 codes. We included patients who underwent surgical treatment, specifically fracture fixation, at our institution and excluded patients with fractures involving the pelvis, spine, foot, and hand. A total of 384 gunshot-associated long bone fractures in 347 patients were identified for analysis. Relevant patient-, injury-, and treatment-related variables were extracted from clinical records and radiographic reviews. Outcomes of interest included bony union, repeat operative procedures, and the development of deep infection. RESULTS: 347 patients with 384 long bone fractures were included. 32 fractures in 32 patients developed an infection for an incidence of 9.3% of patients and 8.3% of fractures. Gram-positive bacteria were present in 23/32 (72.0%) culture isolates, gram-negative bacteria in 10/32 (31.3%) culture isolates, and six infections were polymicrobial. Staphylococcus 16/32 (50.0%) and Enterobacter 6/32 (18.8%) species were the most common isolates. Of the Staphylococcus species, 5/16 (31.3%) were MRSA. Lower extremity fractures had a greater risk for infection compared to the upper extremity (11.7% vs 3.7% p < 0.01) and fractures that developed an infection had a larger average zone of comminution (63.9 mm vs 48.5 mm p < 0.05). CONCLUSION: This study investigated the rates of infection associated with long bone fractures caused by civilian gunshots. The overall infection rate observed in our series aligns with existing literature. Gram-positive bacteria were the predominant isolates, with a notable incidence of MRSA in our patient population, highlighting the need for considering empiric coverage. Additionally, gram-negative organisms were found in a significant proportion of infections, and a notable percentage of infections were polymicrobial. Our findings emphasize the importance of carefully assessing highly comminuted lower extremity fractures and implementing appropriate antibiotic coverage and operative debridement for patients with gunshot-related long bone fractures. While current prophylaxis algorithms for open fractures lack specific inclusion of gunshot wounds, we propose incorporating these injuries to reduce the incidence of infections associated with such fractures.

Nanostring-Based Identification of the Gene Expression Profile in Trigger Finger Samples.

Trigger finger is a common yet vastly understudied fibroproliferative hand pathology, severely affecting patients' quality of life. Consistent trauma due to inadequate positioning within the afflicted finger's tendon/pulley system leads to cellular dysregulation and eventual fibrosis. While the genetic characteristics of the fibrotic tissue in the trigger finger have been studied, the pathways that govern the initiation and propagation of fibrosis are still unknown. The complete gene expression profile of the trigger finger has never been explored. Our study has used the Nanostring nCounter gene expression assay to investigate the molecular signaling involved in trigger finger pathogenesis. We collected samples from patients undergoing trigger finger (n = 4) release surgery and compared the gene expression to carpal tunnel tissue (n = 4). Nanostring nCounter analysis identified 165 genes that were differentially regulated; 145 of these genes were upregulated, whereas 20 genes were downregulated. We found that several collagen genes were significantly upregulated, and a regulatory matrix metalloproteinase (MMP), MMP-3, was downregulated. Bioinformatic analysis revealed that several known signaling pathways were dysregulated, such as the TGF-ß1 and Wnt signaling pathways. We also found several novel signaling pathways (e.g., PI3K, MAPK, JAK-STAT, and Notch) differentially regulated in trigger finger. The outcome of our study helps in understanding the molecular signaling pathway involved in the pathogenesis of the trigger finger.

Sex-Specific Differences in Extracellular Vesicle Protein Cargo in Synovial Fluid of Patients with Osteoarthritis.

Women are at a significantly higher risk of developing osteoarthritis (OA) compared to males. The pathogenesis of osteoarthritis (OA) in women is poorly understood. Extracellular vesicles (EVs) have been shown to play an essential role in numerous signaling processes during the pathogenesis of age-related diseases via paracrine signaling. Molecular profiling of the synovial fluid-derived EVs cargo in women may help in the discovery of novel biomarkers and therapeutics for the treatment of OA in women. Previously, we reported that synovial fluid-derived EV miRNA cargo differs in a sex-specific manner. This study aims to characterize synovial fluid-derived EV protein cargo in OA patients. Our data showed sex-specific EVs protein content in OA. We found haptoglobin, orosomucoid, and ceruloplasmin significantly up-regulated, whereas apolipoprotein down-regulated in female OA EVs. In males, we discovered ß-2-glycoprotein, and complement component 5 proteins significantly up-regulated and Spt-Ada-Gcn5 acetyltransferase (SAGA)-associated factor 29 down-regulated in male OA EVs. Database for Annotation, Visualization, and Integrated Discovery (DAVID) and QuickGO analysis revealed OA-specific protein involvement in several biological, molecular, and cellular pathways, specifically in inflammatory processes. In conclusion, synovial fluid EV protein content is altered in a sex-specific manner with OA, explaining the increased prevalence and severity of OA in women.

Dysregulation of epigenetic related genes in Diabetic Trigger finger Patients; preliminary analysis of Patient-Derived Samples.

BACKGROUND: Trigger finger (TF), a painful condition involving a finger flexor tendon, is a common problem with a prevalence of ~2-3% in the general population. However, the TF prevalence is higher among diabetic patients-ranges from 6.7% to 10%. We have analyzed the expression of the extracellular matrix, inflammation, and epigenetic related genes in diabetic and non-diabetes TF. We hypothesized that Diabetes condition induces alter the expression of epigenetic modification genes in diabetic patients and one of the underlying determinants for more prevalence of TF in diabetic patients. METHOD: Tissues from the fingers of patients with symptomatic trigger fingers were collected. We had three groups: carpal tunnel syndrome (as a control), trigger finger, and diabetic trigger finger. A quantitative real-time polymerase chain reaction was performed. The gene expression of Extracellular matrix (ECM) components [COL-I, COL-II, COL-X, Aggrecan], DNA methyltransferases enzymes (DNMT1, DNMT3), growth factors (TGF-b, IGF), and Histone deacetylase enzymes (HDAC1, HDAC2) were evaluated in all groups. RESULTS: The mRNA expression of COL-I, COL-II, Aggrecan was significantly higher in the pully A1 of diabetic patients (p= 0.0164, p=0.0351, p=0.0399, respectively) as compared to non-diabetic TF patients. Diabetes was associated with a significant increase in the DNMT3 expression compared to non-diabetic TF patients (p=0.0485). HDAC1 and HDAC2 gene expression were up-regulated in diabetic TF than non-diabetic TF. CONCLUSION: The chronic state of hyperglycemia induces epigenetic modification of gene expressions in trigger fingers. This seems to have a significant impact on the development, recurrence, and progression of trigger finger in diabetic patients.