Surgical Treatment of Severe Heterotopic Ossification After Total Hip Arthroplasty Over the Last 25 Years: A Systematic Review of the Literature and a New Case Series.

BACKGROUND: Severe heterotopic ossification (HO) (grades III and IV) after total hip arthroplasty (THA) over the last 25 years requiring excision is very uncommon. We performed a systematic review of the literature and reported a new case series with operative treatment after primary uncemented THA. METHODS: A systematic review identified papers describing patients who had excision of HO after THA performed after 1988. Concepts of hip arthroplasty, HO, and surgical excision were searched in MEDLINE, Embase, and Scopus from database inception to November 2022. The inclusion criteria were articles that included specific patient data on the grade of HO, operative procedure, and prophylaxis. Studies were screened for inclusion by 2 independent reviewers. The extracted data included demographic data, the interval from index surgery to excision, clinical results, and complications. There was one surgeon who performed reoperation for ankylosis of primary THA in 3 men who had severe pain and hip deformity. RESULTS: Data from 7 studies were included. There were 41 patients who had grade III or IV HO who had excision, and in 5 patients, revision of a component was also performed. Perioperative prophylaxis was irradiation alone in 10 patients, irradiation and indomethacin in 10 patients, and indomethacin alone in 21 patients. At a mean follow-up time of 14.8 months, the definition of the results was not uniform, and range of motion was improved, but relief of pain was inconsistent. There was one dislocation after resection without revision, one gastrointestinal complication, and 2 recurrences. Treatment of the 3 new patients, with wide excision of periarticular bone, selective exchange of components, and perioperative irradiation prophylaxis, was successful in improving pain, motion, and deformity. CONCLUSIONS: There is insufficient good-quality data on the operative treatment of severe symptomatic HO after THA performed over the last 25 years. Prophylaxis with low-dose irradiation prevented a recurrence. Multicenter studies are needed to determine the optimum timing and prognosis for treatment.

Risk of Infection Following Gunshot Wound Fractures to the Foot and Ankle: A Multicenter Retrospective Study.

The purpose of this multicenter retrospective chart review was to describe demographics, fracture and wound characteristics, and treatments for foot and/or ankle fractures caused by gunshot wounds (GSWs) and identify factors that increase risk of infection in adults treated at 5 urban level 1 trauma centers in South and Midwest regions of the United States. A total of 244 patients sustained GSW-related fractures of the foot/ankle during 2007-2017, of whom 179 had ≥30 days of follow-up data after the initial injury. Most patients were male (95.1%; 232/244) with an average age of 31.2 years. On average, patients sustained 1.3 GSWs (range 1-5) to the foot/ankle. Most GSWs were categorized as low energy (85.1%; 171/201) and the majority (58.2%; 142/244) had retained bullet fragments. Antibiotics were administered at initial presentation to 78.7% (192/244) of patients and 41.8% (102/244) were managed operatively at the time of initial injury. Nerve injury, vascular injury, and infection were documented in, respectively, 8.6% (21/243), 6.6% (16/243), and 17.2% (42/244) of all cases. Multivariable analysis revealed that high-energy injuries and retained bullet fragments increased the risk of infection by 3-fold (odds ratio 3.09, 95% confidence interval 1.16-8.27, p = .025) and 3.5-fold (OR 3.48, 95% CI1.40-8.67; p = .008), respectively. Side of injury, primary injury region, and vascular injury were not significant predictors of infection risk. Further research should examine whether retained bullet fragments are directly associated with infection risk and support the development of guidelines regarding the management of patients with GSW-related fractures to the ankle/foot.

The Clamshell Osteotomy for Diaphyseal Malunion in Deformity Correction and Fracture Surgery.

Diaphyseal malunion poses a great challenge for the orthopedic surgeon, and an inundation of morbidity for the patient. Diaphyseal malunion can cause altered gait, adjacent joint osteoarthritis and body dissatisfaction. This problem is fraught with complications without surgical intervention. There is a myriad of options for the management of a diaphyseal malunion. The clamshell osteotomy was engendered to ameliorate the difficulty in managing this issue. This technique is a viable option to correct diaphyseal malunion about the femur and tibia. Recently, the indications of a clamshell osteotomy have been expanded to function as a derotational or shortening osteotomy.

Evidence of climate-driven ecosystem reorganization in the Gulf of Mexico.

The Gulf of Mexico is one of the most ecologically and economically valuable marine ecosystems in the world and is affected by a variety of natural and anthropogenic phenomena including climate, hurricanes, coastal development, agricultural runoff, oil spills, and fishing. These complex and interacting stressors, together with the highly dynamic nature of this ecosystem, present challenges for the effective management of its resources. We analyze a compilation of over 100 indicators representing physical, biological, and economic aspects of the Gulf of Mexico and find that an ecosystem-wide reorganization occurred in the mid-1990s. Further analysis of fishery landings composition data indicates a major shift in the late 1970s coincident with the advent of US national fisheries management policy, as well as significant shifts in the mid-1960s and the mid-1990s. These latter shifts are aligned temporally with changes in a major climate mode in the Atlantic Ocean: the Atlantic Multidecadal Oscillation (AMO). We provide an explanation for how the AMO may drive physical changes in the Gulf of Mexico, thus altering higher-level ecosystem dynamics. The hypotheses presented here should provide focus for further targeted studies, particularly in regard to whether and how management should adjust to different climate regimes or states of nature. Our study highlights the challenges in understanding the effects of climatic drivers against a background of multiple anthropogenic pressures, particularly in a system where these forces interact in complex and nonlinear ways.

Heterotopic Ossification After Modern Total Hip Arthroplasty: Predisposing Factors, Prophylaxis, and Surgical Treatment.

Heterotopic ossification (HO) is a common radiographic finding and potentially serious complication after modern total hip arthroplasty. Although historically associated with the posterolateral approach, HO has been noted in 10% to 40% of patients having direct anterior or anterior-based muscle sparing approaches. The available data are uncertain whether robotic arm-assisted procedures are associated with this complication. Current prophylaxis for patients considered high risk of this complication includes postoperative, nonsteroidal, anti-inflammatory medication for several weeks or low-dose perioperative irradiation. The surgical treatment of symptomatic HO associated with severely restricted motion or ankylosis of the hip should be individualized but may include wide excision of bone, acetabular revision to prevent instability, and prophylaxis to prevent recurrence.

Treating Sleep Disorders After Total Hip and Total Knee Arthroplasty.

Disorders of sleep are common after total hip and knee arthroplasty and may contribute to patient dissatisfaction and poorer outcomes in the early postoperative period. Multiple factors contribute to sleep disorders, including poorly controlled pain, opioid medication, perioperative stress, and anxiety. Both pharmacologic and nonpharmacologic methods have been used for perioperative sleep disorders, but there is no consensus on the optimal treatment.

Tibial Shaft and Pilon Fractures With Associated Syndesmotic Injury: A Matched Cohort Assessment.

OBJECTIVE: To determine the outcomes of pilon and tibial shaft fractures with syndesmotic injuries compared with similar fractures without syndesmotic injury. DESIGN: Retrospective case-control study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: All patients over a 5-year period (2012-2017) with tibial shaft or pilon fractures with a concomitant syndesmotic injury and a control group without a syndesmotic injury matched for age, OTA/AO fracture classification, and Gustilo-Anderson open fracture classification. INTERVENTION: Preoperative or intraoperative diagnosis of syndesmotic injury with reduction and fixation of both fracture and syndesmosis. MAIN OUTCOME MEASUREMENT: Rates of deep infection, nonunion, unplanned reoperation, and amputation in patients with a combined syndesmotic injury and tibial shaft or pilon fracture versus those without a syndesmotic injury. RESULTS: A total of 30 patients, including 15 tibial shaft and 15 pilon fractures, were found to have associated syndesmotic injuries. The matched control group comprised 60 patients. The incidence of syndesmotic injury in all tibial shaft fractures was 2.3% and in all pilon fractures was 3.4%. The syndesmotic injury group had more neurologic injuries (23.3% vs. 8.3% P = 0.02), more vascular injuries not requiring repair (30% vs. 15%, P = 0.13), and a higher rate compartment syndrome (6.7% vs. 0%, P = 0.063). Segmental fibula fracture was significantly more common in patients with a syndesmotic injury (36.7% vs. 13.3%, P = 0.04). Fifty percent of the syndesmotic injury group underwent an unplanned reoperation with significantly more unplanned reoperations (50% vs. 27.5%, P = 0.04). The syndesmotic group had a significantly higher deep infection rate (26.7% vs. 8.3% P = 0.047) and higher rate of amputation (26.7% vs. 3.3% P = 0.002) while the nonunion rate was similar (17.4% vs. 16.7% P = 0.85). CONCLUSIONS: Although syndesmotic injuries with tibial shaft or pilon fractures are rare, they are a marker of a potentially limb-threatening injury. Limbs with this combined injury are at increased risk of deep infection, unplanned reoperation, and amputation. The presence of a segmental fibula fracture should raise clinical suspicion to evaluate for syndesmotic injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A track record of diversity: Medical schools ranked by successful black applicants to orthopaedic residencies.

BACKGROUND: Orthopaedic surgery is the least diverse surgical subspecialty in medicine. However, to date, there is no literature that shows which medical schools have successfully contributed to improving orthopaedic surgeon diversity. OBJECTIVE: The purpose of this study is to identify the top U.S. medical schools that have successfully matched black applicants into orthopaedic surgery residencies and juxtapose this ranking to the current top medical schools as ranked by the U.S. News and World Report (USNWR). METHODS: The J. Robert Gladden Orthopaedic Society (JRGOS) database was queried for all orthopaedic surgeons, fellows, and residents who identified as black or multi-racial with black being one of the included races, yielding 938 physicians, of which 672 met our inclusion criteria. From this list, a ranking of the top 20 medical schools was generated. RESULTS: The top five medical schools ranked in the JRGOS database are Howard University College of Medicine (HUCOM), Meharry Medical College, Harvard Medical School (HMS), the University of Pennsylvania, and Morehouse School of Medicine (MSM). In addition, 10 (50%) of the medical schools ranked in the top 20 by the JRGOS database were also ranked by the USNWR. When ranking medical schools for black female applicants, HUCOM, MSM, HMS are the top three programs. Lastly, a ranking by region identified that the northeast contained the highest number of ranked medical schools. CONCLUSION: There are both historically black and non-historically black medical schools which have a proven track record of producing a significant number of future black orthopaedic surgery residents.

Unicompartmental Knee Arthroplasty Is Not Associated With Increased Revision Rates in Obese Patients.

BACKGROUND: There is controversy among arthroplasty surgeons in regard to performing unicompartmental knee arthroplasty (UKA) in obese patients based on current literature. The aim of this study is to investigate whether UKA is associated with increased complications and revision rates in obese (body mass index [BMI] > 30 kg/m2), morbidly obese (BMI > 40 kg/m2), and super morbid obese (BMI > 50 kg/m2) patients. METHODS: We retrospectively reviewed all UKAs performed at our institution from January 2008 to December 2017. A total of 2178 UKA procedures were performed during this period. The patients were categorized based on BMI to include normal weight (BMI = 20-30 kg/m2), obese (BMI ≥ 30.1-40 kg/m2), morbidly obese (BMI ≥ 40.1-50 kg/m2), and super morbid obese (BMI ≥ 50.1 kg/m2) groups. Record review was performed to obtain demographic data, need for revision (timing, type, and etiology), and complication rate and cause. RESULTS: The 2178 UKA cases were eligible for inclusion in this investigation. We performed 2028 medial UKAs and 150 lateral UKAs. The mean clinical follow-up period was 3.7 years, and the mean time from index surgery to revision was 7.2 years. Of the 2178 UKA cases, 1167 had a 3-year minimum follow-up. The overall revision rate in all patients was 2.2%. There was no significant difference (P > .05) in revision rates among normal weight (3.0%), obese (2.7%), morbidly obese (1.9%), and super morbid obese patients (1.8%). Most failures in all groups were secondary to progression of osteoarthritis requiring total knee arthroplasty. CONCLUSIONS: Similar rates of revision were found for UKAs performed on obese, morbidly obese, or super morbid obese patients (≤2.0% revision rate) vs normal BMI (2.7% revision rate) patients. Progressive osteoarthritis was the most common mechanism of UKA failure. Obesity is not a contraindication for UKA despite previous recommendations to the contrary.

Breeding Brown Pelicans Improve Foraging Performance as Energetic Needs Rise.

Optimal foraging theory states that animals should maximize resource acquisition rates with respect to energy expenditure, which may involve alteration of strategies in response to changes in resource availability and energetic need. However, field-based studies of changes in foraging behavior at fine spatial and temporal scales are rare, particularly among species that feed on highly mobile prey across broad landscapes. To derive information on changes in foraging behavior of breeding brown pelicans (Pelecanus occidentalis) over time, we used GPS telemetry and distribution models of their dominant prey species to relate bird movements to changes in foraging habitat quality in the northern Gulf of Mexico. Over the course of each breeding season, pelican cohorts began by foraging in suboptimal habitats relative to the availability of high-quality patches, but exhibited a marked increase in foraging habitat quality over time that outpaced overall habitat improvement trends across the study site. These findings, which are consistent with adjustment of foraging patch use in response to increased energetic need, highlight the degree to which animal populations can optimize their foraging behaviors in the context of uncertain and dynamic resource availability, and provide an improved understanding of how landscape-level features can impact behavior.

Landscape genetics reveal broad and fine-scale population structure due to landscape features and climate history in the northern leopard frog (Rana pipiens) in North Dakota.

Prehistoric climate and landscape features play large roles structuring wildlife populations. The amphibians of the northern Great Plains of North America present an opportunity to investigate how these factors affect colonization, migration, and current population genetic structure. This study used 11 microsatellite loci to genotype 1,230 northern leopard frogs (Rana pipiens) from 41 wetlands (30 samples/wetland) across North Dakota. Genetic structure of the sampled frogs was evaluated using Bayesian and multivariate clustering methods. All analyses produced concordant results, identifying a major east-west split between two R. pipiens population clusters separated by the Missouri River. Substructuring within the two major identified population clusters was also found. Spatial principal component analysis (sPCA) and variance partitioning analysis identified distance, river basins, and the Missouri River as the most important landscape factors differentiating R. pipiens populations across the state. Bayesian reconstruction of coalescence times suggested the major east-west split occurred ~13-18 kya during a period of glacial retreat in the northern Great Plains and substructuring largely occurred ~5-11 kya during a period of extreme drought cycles. A range-wide species distribution model (SDM) for R. pipiens was developed and applied to prehistoric climate conditions during the Last Glacial Maximum (21 kya) and the mid-Holocene (6 kya) from the CCSM4 climate model to identify potential refugia. The SDM indicated potential refugia existed in South Dakota or further south in Nebraska. The ancestral populations of R. pipiens in North Dakota may have inhabited these refugia, but more sampling outside the state is needed to reconstruct the route of colonization. Using microsatellite genotype data, this study determined that colonization from glacial refugia, drought dynamics in the northern Great Plains, and major rivers acting as barriers to gene flow were the defining forces shaping the regional population structure of R. pipiens in North Dakota.

Prevalence of methicillin-resistant Staphylococcus aureus nasal carriage in healthcare workers.

Thirty (12%) of 257 healthcare workers were colonized with methicillin-resistant Staphylococcus aureus (MRSA). There was no significant difference in MRSA colonization among physicians (13%), nurses (12%), and other healthcare professionals (11%). Potential risk factors for MRSA colonization were found in 90% or more of all subjects, including those with MRSA and methicillin-susceptible S. aureus nasal carriage, as well as in persons who were not colonized.

Management of Pelvic and Acetabular Fractures in the Obese Patient.

Acetabular and pelvic ring injuries in obese patients are difficult to treat. Obese patients require great attention to detail during the trauma evaluation to prevent medical and anesthetic complications in the perioperative period. Radiographic evaluation is often compromised by modalities available and loss of resolution with plain film imaging. Patient positioning must be meticulous to ensure stability on the bed while allowing access to the operative site, preventing pressure necrosis, and minimizing ventilation pressure. Complications after surgical treatment are common and often due to infection and loss of fixation. Careful technique can mitigate but not prevent these complications.

Lack of usefulness of an abnormal white blood cell count for predicting a concurrent serious bacterial infection in infants and young children hospitalized with respiratory syncytial virus lower respiratory tract infection.

BACKGROUND: There continues to be controversy on the most appropriate way to manage infants and young children with fever and documented RSV lower respiratory tract infection (LRTI). The objective of this study was to determine the usefulness of an abnormal white blood cell (WBC) count for predicting a concurrent serious bacterial infection in patients admitted with RSV LRTI. METHODS: The medical records were reviewed of patients discharged with RSV LRTI during the 5 RSV seasons from July 1, 2000 through June 30, 2005. Data were collected on age and gender as well as temperature, complete blood count with manual differential and bacterial cultures obtained at admission. RESULTS: The inclusion criteria was met by 1920 patients. There were 672 febrile patients who had a complete blood count and a bacterial culture. One (5.0%) of 20 patients with a WBC <5000 had a positive culture, 23 (4.7%) of 492 patients with a WBC 5000-14,999 had a positive culture, 5 (4.8%) of 105 patients with a WBC 15,000-19,999 had a positive culture, 2 (5.7%) of 35 patients with a WBC 20,000-24,999 had a positive culture, none of 11 patients with a WBC 25,000-29,999 had a positive culture and 3 (33%) of 9 patients with a WBC >30,000 had a positive culture. Overall, cultures were positive in 34 (5.1%; 95% CI: 3.4-6.8%) of the febrile patients tested and almost all (32; 94%) showed positive urine cultures. CONCLUSION: The probability of an abnormal WBC count <5000 and 15,000-30,000 being associated with a concurrent serious bacterial infection was very low and no different from that of a normal WBC count in febrile patients admitted with RSV LRTI.

Respiratory syncytial virus laboratory surveillance and hospitalization trends in South Texas.

Surveillance of seasonal variations in respiratory syncytial virus (RSV) outbreaks is an important component in clinical decision-making. A retrospective analysis of 11 years of laboratory-based RSV surveillance and 7 years of hospitalization data was carried out to better define the onset and duration of the RSV season in South Texas, as well as to evaluate the clinical impact and timing of RSV outbreaks on the number of infants hospitalized with RSV infection. All but one of the seasons examined lasted longer than the national and southern seasons reported by the Centers for Disease Control and Prevention. In addition, most seasons started earlier and ended later than the national and regional seasons. Considerable parallels were noted between RSV hospital admission frequency and number of RSV-positive tests, as determined by rapid antigen detection or viral culture. Taken together, these results reflect the clinical utility of RSV surveillance data and highlight the impact of RSV on infant hospitalization.

Fleet behavior is responsive to a large-scale environmental disturbance: Hypoxia effects on the spatial dynamics of the northern Gulf of Mexico shrimp fishery.

The northwestern Gulf of Mexico shelf experiences one of the largest seasonal hypoxic zones in the western hemisphere. Hypoxia (dissolved oxygen, DO ≤ 2.0 mg·L-1) is most severe from May to August during the height of the Gulf shrimp fishery, but its effects on the fishery are not well known. Prior studies indicate that hypoxia alters the spatial dynamics of shrimp and other species through habitat loss and aggregation in nearby oxygenated refuge habitats. We hypothesized that hypoxia-induced changes in the distribution of shrimp also alter the spatial dynamics of the Gulf shrimp fleet. We integrated data on the geographic distribution of shrimp tows and bottom DO to evaluate the effects of hypoxia on spatial patterns in shrimping effort. Our analyses indicate that shrimping effort declines in low DO waters on both the Texas and Louisiana shelf, but that considerable effort still occurs in low DO waters off Louisiana, likely because riverine nutrients fuel both benthic production and low bottom DO in the same general regions. The response of the shrimp fleet to hypoxia on the Louisiana shelf was complex with shifts in effort inshore, offshore, westward, and eastward of the hypoxic zone, as well as to an oxygenated area between two hypoxia regimes associated with the Mississippi and the Atchafalaya River outflows. In contrast, effort on the Texas shelf mostly shifted offshore in response to low DO but also shifted inshore in some years. Spatial patterns in total shrimping effort were driven primarily by the number of shrimp tows, consistent with aggregation of the fleet outside of hypoxic waters, though tow duration also declined in low DO waters. Overall, our results demonstrate that hypoxia alters the spatial dynamics of the Gulf shrimp fishery with potential consequences for harvest interactions and the economic condition of the fishery.

Economic impact of the community-acquired methicillin-resistant Staphylococcus aureus epidemic on the Driscoll Children's Health Plan.

Cellulitis and abscess accounted for increasing percentages of inpatient (4.6-11.1%), outpatient (0.6-1.2%) and total (1.7-3.3%) expenses from 2001 through 2004. The per member per month expenses attributed to cellulitis and abscess increased from $0.74 in 2001 to $1.19 in 2004. The epidemic of community-acquired methicillin-resistant Staphylococcus aureus infections in children has had a significant economic impact on the Driscoll Children's Health Plan.

Prevalence of methicillin-resistant Staphylococcus aureus nasal carriage in patients admitted to Driscoll Children's Hospital.

A nasal swab specimen was collected for culture within 48 hours of admission and a questionnaire was completed using a convenience sample of 350 patients admitted to Driscoll Children's Hospital between February 15 and March 15, 2005. Of the 350 patients enrolled, 125 (36%) patients were colonized with Staphylococcus. aureus and 76 (61%) of the 125 S. aureus isolates were methicillin-resistant.