Factors That Influence Time to Operating Room for Geriatric Hip Fractures: A Quality Improvement Initiative.

Background: For geriatric hip fractures, the current American College of Surgeons guideline recommends surgery within 48 hours. We sought to identify which factors delayed a patient's progression to definitive surgery at 2 associated level II trauma centers using chart abstraction. Methods: We reviewed all geriatric patients who underwent a surgical procedure for a hip fracture. Data regarding age, length of stay, procedure, and minutes from emergency department arrival to operating room (OR) were evaluated. Chart abstraction determined if cardiac or medical clearance and an echocardiogram were obtained. For patients that entered the OR over 24 hours, a reason was identified for the delay. Analysis of variance was used to compare continuous data, and chi-squared tests were used for categorical data. Results: Of 477 patients, 288 (60%) presented to the OR in under 24 hours, 114 (24%) between 24 and 36 hours, and 75 (16%) over 36 hours. There was a significant increase in length of stay for patients, over 36 hours. Patients presenting to the OR between 24 and 36 hours were often delayed due to facility reasons such as OR or surgeon availability while patients presenting over 36 hours were delayed due to medical comorbidities. Of all patients in the under-24-hours group, 34.7% had an echocardiogram compared with 56.1% and 69.3%, respectively. Similarly, 17.7% of patients received cardiac clearance in the under-24-hours group, compared with 31.8% and 48%, respectively. Conclusions: The timeliness of presentation of hip fractures to the OR is a multidisciplinary effort and requires cooperation between a variety of services to increase safety and efficiency as well as to control costs.

Attachment and Growth of Fibroblasts and Tenocytes Within a Porous Titanium Scaffold: A Bioreactor Approach.

Background: Direct attachment of tendons to metallic implants is important in orthopedics. Tissue integration depends on scaffold microstructure and composition. This study evaluated the effect of pore size of titanium on the viability and function of fibroblasts and tenocytes in a dynamic bioreactor. Methods: Standardized Ti porous cylinders with 3 pore sizes (400, 700, and 1000 µm) were seeded with fibroblasts or tenocytes (4500 cells/µL) in silicon tubes. Cells were analyzed via alamarBlue (AB) assay in addition to scanning electron microscopy at day 7 (fibroblasts) or day 8 (tenocytes) and day 15. AB functions as a cell health indicator where functional living cells reduce the resazurin dye (blue) in the solution to resorufin (pink), and cell viability can be quantified via spectroscopy. Results: At day 7, fibroblasts cultured on all sizes reduced AB, with significant differences noted between 400 vs 1000 µm (P = .013) and 700 vs 1000 µm (P = .001). At day 15, fibroblasts reduced AB on all sizes with a significant difference noted between 700 vs 1000 µm (P = .004). Fibroblasts on all 3 pore sizes increased AB reduction from day 7 to day 15. Tenocytes reduced AB with significant differences between the 400 vs 700 µm (P = .049) and the 400 vs 1000 µm pore sizes at day 8. In contrast, tenocyte reduction of AB decreased from day 8 to day 15. Scanning electron microscopy performed on fibroblast cylinders showed fibroblasts reached the surface of the cylinders, confirming interconnectivity. Conclusions: While both fibroblasts and tenocytes penetrated the pores, fibroblasts preferred larger size, whereas tenocytes favored smaller size. Results are encouraging since soft-tissue attachment to a metallic scaffold is difficult but clinically desirable. Future studies could be performed in an in vivo animal model.

Mark Coventry Award: Efficacy of Saline Wash Plus Antibiotics Doped Polyvinyl Alcohol (PVA) Composite (PVA-VAN/TOB-P) in a Mouse Pouch Infection Model.

BACKGROUND: The efficacy of saline irrigation for treatment of periprosthetic infection (PJI) is limited by the presence of contaminated medical devices. This study evaluated treatment efficacy of locally placed polyvinyl alcohol (PVA)/bioceramic composite doped with vancomycin (PVA-VAN-P) or vancomycin and tobramycin (PVA-VAN/TOB-P) after saline irrigation in a mouse pouch infection model. METHODS: Sutures were implanted into air pouches of BALB/cJ mice, then inoculated with Staphylococcus aureus. Mice were randomized into 6 groups (n = 6 each): (1) no bacteria; (2) bacteria without saline wash; (3) saline wash only; (4) saline wash + PVA-P; (5) saline wash + PVA-VAN-P, and (6) saline wash + PVA-VAN/TOB-P. After 7 days, pouches were washed with saline alone or with additional injection of 0.2 mL of the composites. Sacrifice occurred 14 days after the washout. Histology was performed on the pouch tissues and bacteria cultures on the washout fluid. RESULTS: Bacterial culture (optical density) showed that infection persisted after saline irrigation (0.10 ± 0.14) but was effectively eradicated by the addition of PVA-VAN-P (0.05 ± 0.09) and PVA-VAN/TOB-P (0.002 ± 0.003, P < .05). These effects were confirmed by histology. Importantly, no residues of the PVA-P were detected in either the pouch washouts or pouch tissues. CONCLUSION: PJI is common and problematic, and few innovations have changed clinical practice and/or outcome. Our data confirmed that the effect of saline irrigation was very limited in the presence of contaminated sutures. PVA-VAN/TOB-P was biodegradable, biocompatible, and effective in eradicating bacterial retention after saline irrigation. Application of PVA-VAN/TOB-P after saline irrigation could be an option for treatment of PJI and should be evaluated in future PJI animal models.

Categorization of Adverse Events Reported to the FDA Pertaining to Tibia Intramedullary Nailing.

OpenFDA is an open access database maintained by the United States Food and Drug Administration (FDA) that we queried for adverse events (AEs) related to product devices used during tibia intramedullary nailing (IMN) procedures. There was a total of 1,799 reports pertaining to tibial intramedullary nailing from 1996 to 2020. Causes included infection (451), nonunion (380), intraoperative issue (343), painful hardware (234), implant fracture (195), other (68), loosening (35), surgeon error (24), packing problem (24), patient injury (12), expiration (12), contamination (11) and allergic reaction (10). The total number of events increased in 2016 and 2018, which was attributed to 510k approval for Stryker. Of the Aes, 1,400 resulted in an injury to the patient. In total, 78% occurred in the post-operative period, and 68% required additional surgery. Most incidents related to tibia IMNs result in injury and require additional surgery. When new products are released, AEs occur quickly and in bulk. (Journal of Surgical Orthopaedic Advances 31(4):237-241, 2022).

Street Smarts and a Scalpel: Emotional Intelligence in Surgical Education.

OBJECTIVE: To evaluate trends of emotional intelligence (EI) in surgical education and to compare the incorporation of EI in surgical education to other fields of graduate medical education. DESIGN: A MEDLINE search was performed for publications containing both "surgery" and "emotional intelligence" with at least one term present in the title. Articles were included if the authors deemed EI in surgical education to be a significant focus. A separate series of MEDLINE searches were performed with the phrase "emotional intelligence" in any field and either "surg*," "internal medicine," "pediatric," "neurology," "obstetric," "gynecology," "OBGYN," "emergency," or "psychiat*" in the title. Articles were included if they discussed resident education as the primary subject. Next, a qualitative analysis of the articles was performed, with important themes from each article noted. SETTING: Lehigh Valley Health Network in Allentown, PA. RESULTS: Eight articles addressed surgical resident education and satisfied inclusion criteria with 0, 1, and 7 articles published between 2001 and 2005, 2005 and 2010, and 2010 and 2015, respectively. The comparative data for articles on EI and resident education showed the following : 8 in surgery, 2 in internal medicine, 2 in pediatrics, 0 in neurology, 0 in OBGYN, 1 in emergency medicine, and 3 in psychiatry. CONCLUSIONS: Integration of EI principles is a growing trend within surgical education. A prominent theme is quantitative assessment of EI in residents and residency applicants. Further study is warranted on the integration process of EI in surgical education and its effect on patient outcomes and long-term job satisfaction.

Lesser tuberosity osteotomy and subscapularis tenotomy repair techniques during total shoulder arthroplasty: A meta-analysis of cadaveric studies.

BACKGROUND: Numerous techniques have been used to mobilize and repair the subscapularis tendon during total shoulder arthroplasty. The purpose of this study is to perform a detailed comparison of subscapularis tenotomy and lesser tuberosity osteotomy repairs during total shoulder arthroplasty. METHODS: Two independent reviewers searched two databases (PubMed and the Cochrane Library) to find cadaveric studies comparing the biomechanical strength of various subscapularis repair techniques following total shoulder arthroplasty. Articles that compared at least two repair techniques with similar biomechanical methods were included. FINDINGS: An initial literature search resulted in 145 studies. A title and abstract review resulted in five studies which analyzed outcomes of subscapularis tenotomy (total n=29) or lesser tuberosity osteotomy using a single- or dual-row suture technique (total n=46). Load to failure was significantly higher in the lesser tuberosity osteotomy group (M 443, SD 231N) than the tenotomy group (M 350, SD 113N) (p=0.047). Tenotomy (n=19) and lesser tuberosity osteotomy (n=31) had average cyclic displacements of 1.7mm (SD 1.3) and 2.1mm (SD 1.6), respectively (p=0.34). Mode of failure was significantly different between the two groups (p<0.0001), with soft tissue failure accounting for most tenotomy repairs (97%) and bone failure accounting for the majority of lesser tuberosity osteotomy repairs (72%). INTERPRETATION: Based on current biomechanical data, lesser tuberosity osteotomy is a stronger repair than a subscapularis tenotomy at "time-zero" in terms of load to failure. However, cyclic displacement did not differ statistically between the two techniques.