Non-neutralizing antibodies targeting the immunogenic regions of HIV-1 envelope reduce mucosal infection and virus burden in humanized mice.

Antibodies are principal immune components elicited by vaccines to induce protection from microbial pathogens. In the Thai RV144 HIV-1 vaccine trial, vaccine efficacy was 31% and the sole primary correlate of reduced risk was shown to be vigorous antibody response targeting the V1V2 region of HIV-1 envelope. Antibodies against V3 also were inversely correlated with infection risk in subsets of vaccinees. Antibodies recognizing these regions, however, do not exhibit potent neutralizing activity. Therefore, we examined the antiviral potential of poorly neutralizing monoclonal antibodies (mAbs) against immunodominant V1V2 and V3 sites by passive administration of human mAbs to humanized mice engrafted with CD34+ hematopoietic stem cells, followed by mucosal challenge with an HIV-1 infectious molecular clone expressing the envelope of a tier 2 resistant HIV-1 strain. Treatment with anti-V1V2 mAb 2158 or anti-V3 mAb 2219 did not prevent infection, but V3 mAb 2219 displayed a superior potency compared to V1V2 mAb 2158 in reducing virus burden. While these mAbs had no or weak neutralizing activity and elicited undetectable levels of antibody-dependent cellular cytotoxicity (ADCC), V3 mAb 2219 displayed a greater capacity to bind virus- and cell-associated HIV-1 envelope and to mediate antibody-dependent cellular phagocytosis (ADCP) and C1q complement binding as compared to V1V2 mAb 2158. Mutations in the Fc region of 2219 diminished these effector activities in vitro and lessened virus control in humanized mice. These results demonstrate the importance of Fc functions other than ADCC for antibodies without potent neutralizing activity.

Patient "No-Show" Increases the Risk of 90-Day Complications Following Primary Total Knee Arthroplasty: A Retrospective Cohort Study of 6,776 Patients.

BACKGROUND: Patients who "no-show" (NS) clinical appointments are at a high risk of adverse health outcomes. The objective of this study was to evaluate and characterize the relationship between NS visits prior to primary total knee arthroplasty (TKA) and 90-day complications after TKA. METHODS: We retrospectively reviewed 6,776 consecutive patients undergoing primary TKA. Study groups were separated based on whether patients who NS versus always attended their appointment. A NS was defined as an intended appointment that was not canceled or rescheduled ≤2 hours before the appointment in which the patient did not show. Data collected included total number of follow-up appointments prior to surgery, patient demographics, comorbidities, and 90-day postoperative complications. RESULTS: Patients who have ≥3 NS appointments had 1.5 times increased odds of a surgical site infection (odds ratio (OR) 1.54, P = .002) compared to always attended patients. Patients who were ≤65 years old (OR: 1.41, P < .001), smokers (OR: 2.01, P < .001), and had a Charlson comorbidity index ≥3 (OR: 4.48, P < .001) were more likely to miss clinical appointments. CONCLUSION: Patients who have ≥3 NS appointments prior to TKA had an increased risk for surgical site infection. Sociodemographic factors were associated with higher odds of missing a scheduled clinical appointment. These data suggest that orthopaedic surgeons should consider NS data as an important clinical decision-making tool to assess risk for postoperative complications to minimize complications following TKA.

Early outcomes of a novel bicruciate-retaining knee system: a 2-year minimum retrospective cohort study.

INTRODUCTION: Bicruciate retaining (BCR) total knee arthroplasty (TKA) was designed to simulate natural knee kinematics and improve proprioception by retaining both the ACL and PCL. While the prospect of the design appears favorable to patients, previous designs have demonstrated modest survivorship rates compared to traditional designs. This study aims to report the early functional outcomes and implant survivorship of a novel BCR design. MATERIALS AND METHODS: A multi-center, retrospective study was conducted identifying BCR TKA patients from 2016 to 2017. Patient demographics, quality outcomes, and post-operative complications were collected. A Kaplan-Meier analysis was used to evaluate revision-free survival. RESULTS: One-hundred thirty-three patients with a mean follow-up time of 2.35 ± 0.25 years (range: 2.00-2.87 years) were identified. Patients receiving BCR TKA were, on average, 61.46 ± 9.27 years-old, obese (BMI = 31.80 ± 6.01 kg/m2), predominantly white (71.4%), and female (69.9%). The device was most often implanted using standard instruments (85.7%) compared to computer-assisted navigation (13.5%). Average length-of-stay was 1.77 ± 0.97 days. Six patients had a reoperation; three (2.5%) full revisions occurred for: infection (n = 1), arthrofibrosis (n = 1), and ACL rupture (n = 1); one (0.8%) tibial revision occurred for: arthrofibrosis; two (1.5%) liner exchanges occurred for: infection (n = 1) and arthrofibrosis (n = 1). Kaplan-Meier survivorship analysis of cumulative failure at 2-year showed a survival rate of 96.2% (95% confidence interval, 91.2-98.4%) for all-cause reoperation, 97.3% (91.6-99.1%) for aseptic revision, and 100% for mechanical failure. CONCLUSION: Survivorship was 96.2% for all-cause reoperation, 97.3% for aseptic revision, and 100% for mechanical implant failure at 2-years. This novel BCR TKA demonstrated no implant-related complications and excellent survivorship outcomes over 2 years with comparable revision rates to those previously reported in the literature.

Intraoperative technology increases operating room times in primary total knee arthroplasty.

INTRODUCTION: Optimization of patient outcomes and identification of factors to improve the surgical workflow are increasingly important. Operating room time is one modifiable factor that leads to greater hospital efficiency as well as improved outcomes such as shorter length of stay and fewer infections and readmissions. The aim of this study was to identify factors associated with operative time disparities in total knee arthroplasty (TKA). METHODS: A retrospective review of 7659 consecutive primary TKA cases was conducted. Patient demographic data, discrete operating room (OR) times, use of technology (i.e. robotic-assisted surgery, computer navigation), surgeon experience and the level of training of the first assistant were collected. Multivariate regression analysis was used to determine the effect of hospital characteristics on operative times. Operative times of five minutes or greater were considered to be clinically significant. RESULTS: While the use of technology (182.64 ± 39.85 vs 158.70 ± 37.45 min; B = 26.09; p < 0.0001) and greater surgeon experience (162.14 ± 39.87 vs 158.69 ± 33.18 min, B = 3.15, p = 0.002) were found to increase OR times, level of training of the first assist (161.65 vs 156.4 min; Β = - 0.264; p = 0.487) did not. Of the discrete OR times examined, incision time and total time under anesthesia were negatively impacted by the use of technology. CONCLUSION: Use of technology was the only study variable found to significantly increase OR times. With increased operative times and limited evidence that technology improves long-term patient outcomes, surgeons should carefully consider the benefits and cost of technology in TKA.

The effects of tourniquet on cement penetration in total knee arthroplasty.

PURPOSE: Aseptic loosening is a common cause of implant failure following total knee arthroplasty (TKA). Cement penetration depth is a known factor that determines an implant's "strength" and plays an important role in preventing aseptic loosening. Tourniquet use is thought to facilitate cement penetration, but its use has mixed reviews. The aim of this study was to compare cement penetration depth between tourniquet and tourniquet-less TKA patients. METHODS: A multicenter retrospective review was conducted. Patients were randomized preoperatively to undergo TKA with or without the use of an intraoperative tourniquet. The variables collected were cement penetration measurements in millimeters (mm) within a 1-month post-operative period, length of stay (LOS), and baseline demographics. Measurements were taken by two independent raters and made in accordance to the zones described by the Knee Society Radiographic Evaluation System and methodology used in previous studies. RESULTS: A total of 357 TKA patients were studied. No demographic differences were found between tourniquet (n = 189) and tourniquet-less (n = 168) cohorts. However, the tourniquet cohort had statistically, but not clinically, greater average cement penetration depth [2.4 ± 0.6 mm (range 1.2-4.1 mm) vs. 2.2 ± 0.5 mm (range 1.0-4.3 mm, p = 0.01)]. Moreover, the tourniquet cohort had a significantly greater proportion of patients with an average penetration depth within the accepted zone of 2 mm or greater (78.9% vs. 67.3%, p = 0.02). CONCLUSION: Tourniquet use does not affect average penetration depth but increases the likelihood of achieving optimal cement penetration depth. Further study is warranted to determine whether this increased likelihood of optimal cement penetration depth yields lower revision rates.

Effect of documented and undocumented psychiatric conditions on length of stay and discharge destination after total knee arthroplasty.

INTRODUCTION: Length of stay (LOS) and readmissions are quality metrics linked to physician payments and substantially impact the cost of care. This study aims to evaluate the effect of documented and undocumented psychiatric conditions on LOS, discharge location, and readmission following total knee arthroplasty (TKA). METHODS: Retrospective review of all primary, unilateral TKA from 2015 to 2020 at a high-volume, academic orthopedic hospital was conducted. Patients were separated into three cohorts: patients with a documented psychiatric diagnosis (+Dx), patients without a documented psychiatric diagnosis but with an actively prescribed psychiatric medication (-Dx), and patients without a psychiatric diagnosis or medication (control). Patient demographics, LOS, discharge location, and 90 days readmissions were assessed. RESULTS: A total of 2935 patients were included; 1051 patients had no recorded psychiatric medications (control); 1884 patients took at least one psychiatric medication, of which 1161 (61.6%) were in the-Dx and 723 (38.4%) were in the +Dx cohort. Operative time (+Dx, 103.4 ± 29.1 and -Dx, 103.1 ± 28.5 vs. 93.6 ± 26.2 min, p < 0.001 for both comparisons) and hospital LOS stay (+ Dx, 3.00 ± 1.70 and -Dx, 3.01 ± 1.83 vs. 2.82 ± 1.40 days, p = 0.021 and p = 0.006, respectively) were greater for patients taking psychiatric medications when compared to the control group. Patients taking psychiatric medication with or without associated diagnosis were significantly more likely to be discharged to a secondary facility-22.8% and 20.9%, respectively-compared to controls, at 12.5% (p < 0.001). Ninety-day readmission rates did not differ between the control and both psychiatric groups (p = 0.693 and p = 0.432, respectively). CONCLUSION: TKA patients taking psychiatric medications with or without a documented psychiatric diagnosis have increased hospital LOS and higher chances of discharge to a secondary facility. Most patients taking psychiatric medication also had no associated diagnosis. Payment models should consider the presence of undocumented psychiatric diagnoses when constructing metrics. Surgeons and institutions should also direct their attention to identifying, recording, and managing these patients to improve outcomes. LEVEL III EVIDENCE: Retrospective Cohort Study.

The accuracy of component positioning during revision total hip arthroplasty using 3D optical computer-assisted navigation.

INTRODUCTION: Despite the excellent outcomes associated with primary total hip arthroplasty (THA), implant failure and revision continue to burden the healthcare system. The use of computer-assisted navigation (CAN) offers the potential for more accurate placement of hip components during surgery. While intraoperative CAN systems have been shown to improve outcomes in primary THA, their use in the context of revision total hip arthroplasty (rTHA) has not been elucidated. We sought to investigate the validity of using CAN during rTHA. METHODS: A retrospective analysis was performed at an academic medical institution identifying all patients who underwent rTHA using CAN from 2016-2019. Patients were 1:1 matched with patients undergoing rTHA without CAN (control) based on demographic data. Cup anteversion, inclination, change in leg length discrepancy (ΔLLD) and change in femoral offset between pre- and post-operative plain weight-bearing radiographic images were measured and compared between both groups. A safety target zone of 15-25° for anteversion and 30-50° for inclination was used as a reference for precision analysis of cup position. RESULTS: Eighty-four patients were included: 42 CAN cases and 42 control cases. CAN cases displayed a lower ΔLLD (5.74 ± 7.0 mm vs 9.13 ± 7.9 mm, p = 0.04) and greater anteversion (23.4 ± 8.53° vs 19.76 ± 8.36°, p = 0.0468). There was no statistical difference between the proportion of CAN or control cases that fell within the target safe zone (40% vs 20.9%, p = 0.06). Femoral offset was similar in CAN and control cases (7.63 ± 5.84 mm vs 7.14 ± 4.8 mm, p = 0.68). CONCLUSION: Our findings suggest that the use of CAN may improve accuracy in cup placement compared to conventional methodology, but our numbers are underpowered to show a statistical difference. However, with a ΔLLD of ~ 3.4 mm, CAN may be useful in facilitating the successful restoration of pre-operative leg length following rTHA. Therefore, CAN may be a helpful tool for orthopedic surgeons to assist in cup placement and LLD during complex revision cases.

The number of stairs into home do not impact discharge disposition and patient reported outcomes after total joint arthroplasty.

INTRODUCTION: The purpose of this study is to report on the association between the number of stairs to enter home and length of stay (LOS), discharge disposition, and patient reported outcome measures (PROMs) among patients who underwent primary total joint arthroplasty (TJA). MATERIALS AND METHODS: We retrospectively reviewed patients who underwent primary total hip or knee arthroplasty between January 2016 and March 2020. Only patients with documentation of the number of stairs to enter their homes were included in the study. The two cohorts were separated into four groups: none, 1-10, 11-20, and > 20 stairs. Collected variables included demographic data, LOS, discharge disposition, and PROMs. Chi-square and ANOVA were utilized to determine significance. RESULTS: Of the 1116 patients included, 510 underwent THA, and 606 underwent TKA. There was no statistical difference in LOS (THA: p = 0.308; TKA: p = 0.701) and discharge disposition (THA: p = 0.371; TKA: p = 0.484) in both cohorts regardless the number of stairs. There was no statistical difference in FJS-12 scores at 3 months (THA: p = 0.590; TKA: p = 0.206), 12 months (THA: p = 0.217; TKA: p = 0.845), and 21 months (THA: p = 0.782; TKA: p = 0.296) postoperatively for both cohorts. There was no statistical difference in HOOS, JR scores preoperatively (p = 0.278) and at 3 months postoperatively (p = 0.527) for the THA cohort, as well as KOOS, JR scores preoperatively and at 3 and 12 months postoperatively (p = 0.557; p = 0.522; p = 0.747) for the TKA cohort. CONCLUSION: We found no statistical differences in LOS, discharge disposition, and PROMs in patients who underwent TJA, irrespective of the number of stairs negotiated to enter their home. These findings can aid surgeons to provide preoperative education and reassurance to patients who have concerns with their discharge planning due to the walk-up stairway at their residence.

Markers of Immune Activation and Inflammation in Individuals With Postacute Sequelae of Severe Acute Respiratory Syndrome Coronavirus 2 Infection.

BACKGROUND: The biological processes associated with postacute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (PASC) are unknown. METHODS: We measured soluble markers of inflammation in a SARS-CoV-2 recovery cohort at early (<90 days) and late (>90 days) timepoints. We defined PASC as the presence of 1 or more coronavirus disease 2019 (COVID-19)-attributed symptoms beyond 90 days. We compared fold-changes in marker values between those with and without PASC using mixed-effects models with terms for PASC and early and late recovery time periods. RESULTS: During early recovery, those who went on to develop PASC generally had higher levels of cytokine biomarkers including tumor necrosis factor-α (1.14-fold higher mean ratio [95% confidence interval {CI}, 1.01-1.28]; P = .028) and interferon-γ-induced protein 10 (1.28-fold higher mean ratio [95% CI, 1.01-1.62]; P = .038). Among those with PASC, there was a trend toward higher interleukin 6 levels during early recovery (1.29-fold higher mean ratio [95% CI, .98-1.70]; P = .07), which became more pronounced in late recovery (1.44-fold higher mean ratio [95% CI, 1.11-1.86]; P < .001). These differences were more pronounced among those with a greater number of PASC symptoms. CONCLUSIONS: Persistent immune activation may be associated with ongoing symptoms following COVID-19. Further characterization of these processes might identify therapeutic targets for those experiencing PASC.

Aspirin Use for Venous Thromboembolism Prevention Is Safe and Effective in Overweight and Obese Patients Undergoing Revision Total Hip and Knee Arthroplasty.

BACKGROUND: Venous thromboembolism (VTE), defined as pulmonary embolism or deep venous thrombosis, is a rare but serious complication following revision total hip arthroplasty (RTHA) and revision total knee arthroplasty (RTKA). Previous studies show that obesity may be associated with an increased risk for pulmonary embolism, wound complications, and infection. With no current universal standard of care for VTE prophylaxis, we sought to determine whether aspirin prescribed (ASA) is safe and effective in obese patients undergoing RTHA/RTKA. METHODS: A retrospective review of 1578 consecutive RTHA/RTKA cases (751 RTHAs and 827 RTKAs) was conducted identifying patients prescribed 325 or 81 mg ASA. Ninety-day postoperative VTE rates, bleeding, wound complications, deep infections, and mortality were collected. Cohorts were stratified according to body mass index (BMI): normal (18-24.9 kg/m2), overweight (25-29.9 kg/m2), obese (30-34.9 kg/m2), severely obese (35-39.9 kg/m2), and morbidly obese (≥40 kg/m2). RESULTS: The cohort comprised of 335 patients with a normal BMI, 511 were overweight, 408 obese, 232 severely obese, and 92 morbidly obese. Total VTE rates were statistically similar between BMI groups (0.90% vs 0.78% vs 0.74% vs 0.43% vs 0%, P = .89). There were no differences in bleeding rates (0.90% vs 0% vs 0% vs 0.43% vs 0%, P = .08), wound complications (0.30% vs 0.20% vs 0.25% vs 0% vs 0%, P = .93), infection (1.49% vs 1.57% vs 0.98% vs 1.29% vs 1.09%, P = .66), or mortality (0% vs 0.20% vs 0% vs 0% vs 0%, P = .72). CONCLUSION: ASA is safe and effective for VTE prevention in obese patients with similar complication rates to nonobese patients undergoing RTHA/RTKA.

In a Bundled Payment Model, the Costs Associated With Total Joint Replacement in Those Aged Older Than 80 Years Are Significantly Greater.

BACKGROUND: The number of octogenarians requiring a total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) will rise disproportionally in the coming decade. Although outcomes are comparable with younger patients, management of these older patients involves higher medical complexity at a greater expense to the hospital system. The purpose of this study was to compare the cost of care for primary THA and TKA in our bundled care patients aged ≥80 years to those aged 65-80 years. METHODS: A retrospective review of primary TKA (n = 641) and THA (n = 1225) cases from 2013 to 2017 was performed. Patient demographic and admission cost data were collected. Patients were grouped based on surgery type (ie, elective or nonelective THA/TKA) and age group (ie, older [≥80 years old] or younger [65-80 years old]). Multivariate regression analyses were used to account for demographic differences. RESULTS: Elective primary THA in the older cohort (n = 157) cost 24.5% more than the younger cohort (n = 1025) (P < .0001). Elective primary TKA cases in the older cohort (n = 87) cost 17.0% more than the younger cohort's (n = 554) (P < .0001). For nonelective THA cases, the older cohort's (n = 29) episodes cost 39.1% more than the younger cohort (n = 14) (P < .0001). When comparing the <80 elective THA cohort (n = 1025) to the ≥90 cohort (n = 10), the cost difference swelled to 58.7% (P < .0001). CONCLUSION: Although primary THA and TKA in ≥80-year-old patients yield similar outcomes, this study demonstrates that the additional measures required to care for older patients and ensure successful outcomes cost significantly more. Consideration should be given to age as a factor in determining reimbursement in a bundled payment system to reduce the incentive to restrict care to elderly patients.

Low-Dose Aspirin Is Safe and Effective for Venous Thromboembolism Prevention in Patients Undergoing Revision Total Hip Arthroplasty: A Retrospective Cohort Study.

BACKGROUND: Currently, there is no established universal standard of care for prophylaxis against venous thromboembolism (VTE) in orthopedic patients undergoing revision total hip arthroplasty (rTHA). The aim of this study is to determine whether a protocol of 81-mg aspirin (ASA) bis in die (BID) is safe and/or effective in preventing VTE in patients undergoing rTHAs vs 325-mg ASA BID. METHODS: In 2017, a large academic medical center adopted a new protocol for VTE prophylaxis in arthroplasty patients at standard risk. Initially, patients received 325-mg ASA BID but switched to 81-mg ASA BID. A retrospective review (2011-2019) was performed to identify 1361 consecutive rTHA patients and their associated 90-day postoperative complications such as VTE, including pulmonary embolism (PE) and/or deep vein thrombosis (DVT), as the primary outcome; and gastrointestinal and wound bleeding, acute periprosthetic joint infection, and mortality as the secondary outcome. RESULTS: From 2011 to 2017, 973 rTHAs were performed and 13 total VTE cases were diagnosed (1.34%). From 2017 to 2019, 388 rTHAs were performed with 3 total VTE cases identified (0.77%). Chi-squared analyses and logistic regression models showed no differences in rates or odds in postoperative PE (P = .09), DVT (P = .79), PE and DVT (P = .85), and total VTE (P = .38) using either dose. There were also no differences between bleeding complications (P = .14), infection rate (P = .46), and mortality (P = .53). CONCLUSION: Using a protocol of 81-mg of ASA BID is noninferior to 325-mg ASA BID and may be safe and effective in maintaining low rates of VTE in patients undergoing rTHA.

The Effect of Polyethylene Liner Thickness on Patient Outcomes and Failure After Primary Total Knee Arthroplasty.

BACKGROUND: The effect of using thicker liners in primary total knee arthroplasty (TKA) on functional outcomes and aseptic failure rates remains largely unknown. As such, we devised a multicenter study to assess both the clinical outcomes and survivorship of thick vs thin liners after primary TKA. METHODS: A search of our institutional databases was performed for patients having undergone bilateral (simultaneous or staged) primary TKA with similar preoperative and surgical characteristics between both sides. Two cohorts were created: thick liners and thin liners. Outcomes collected were as follows: change in Knee Society Score (ΔKSS), change in range of motion, and aseptic revision. Ad hoc power analysis was performed for ΔKSS (⍺ = 0.05; power = 80%). Differences between cohorts were assessed. RESULTS: About 195 TKAs were identified for each cohort. ΔKSS and change in range of motion in the thin vs thick cohorts were similar: 51.4 vs 51.6 (P = .86) and 11.1° vs 10.0° (P = .66), respectively. No difference in aseptic revision rates were observed between thin and thick cohorts: all cause (4.1%, 3.1%; P = .59), aseptic loosening (0.5%, 0.5%; P = 1.0), instability (0.5%, 0.5%; P = 1.0), all-cause revision for stiffness (3.1%, 2.1%; P = .52), manipulation under anesthesia (2.1%, 2.1%; P = 1.0), and liner exchange (0.5%, 0%; P = .32). CONCLUSION: The results of this study suggest that both rates of revision surgery and clinical outcomes are similar for TKAs performed with thick and thin liners. Preoperative factors are likely to play an important role in liner thickness selection, and emphasis should be placed on ensuring sound surgical technique.

Does Perioperative Radiation Affect Implant Survivorship of Primary Total Hip Arthroplasty in the Setting of Metastatic Bone Disease?

Background: Metastatic bone disease (MBD) commonly affects the hip and surgical intervention including total hip arthroplasty (THA) is often indicated to treat the joint and improve function. Patients with metastatic cancer often receive radiotherapy, and orthopaedic oncologists must consider surgical risks with operating on irradiated bone and soft tissue. We evaluated surgical outcomes and implant survival (IS) of titanium acetabular components and femoral components in patients treated for MBD in the setting of perioperative radiation. Methods: This was a retrospective review of patients who underwent THA for MBD at 3 institutions between 2017 and 2021. Outcomes included rates of reoperation, complications, IS, and overall survival. Results: Forty-six patients who received primary THA for MBD were included in the study. Twenty patients (43.5%) received perioperative radiation for MBD. Six postoperative complications including one superficial wound infection, 2 dislocations, 2 pathologic fractures, and one aseptic acetabular component loosening led to 5 reoperations. There were no significant differences in postoperative outcomes, reoperation after THA, and IS based on radiotherapy status. Conclusions: To our knowledge, this is the first paper evaluating primary THA outcomes and IS between patients who receive perioperative radiation for MBD to the hip and those who do not. As surgical management is a crucial part of the treatment in alleviating pain and disability in patients with MBD, we continue to recommend THA for patients who received radiation at the operative site.

Radiographic Robustness of Lumbar Interbody Fusion Techniques.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: Lumbar interbody fusion (LIF) can be achieved with various techniques. Evidence supporting the long-term clinical advantages of one technique over another are inconclusive. The purpose of this study was to (1) determine the changes in sagittal parameters in the preoperative, intraoperative, and post-operative phase, (2) evaluate the radiographic maintenance of these parameters over time, and (3) compare the demographics and patient reported outcomes of patients undergoing various LIF techniques. METHODS: We performed a retrospective chart review of patients with degenerative spine disease undergoing single level anterior (ALIF), lateral (LLIF), posterior (PLIF), or transforaminal (TLIF) lumbar interbody fusion. Data collected included patient demographics and diagnosis at time of surgery. Upright lumbar radiographs taken pre-operatively, intra-operatively, and post-operatively were measured for lumbar lordosis (LL), segmental lordosis (SL), posterior disc height (PDH), and foraminal height (FH). RESULTS: 194 patients in a single center were included. PDH and FH increased intra-operatively following ALIF (P < .0001), PLIF (P < .0001), LLIF (P < .0001), and TLIF (P < .0001). SL also increased intra-operatively for ALIF (P = .002) and LLIF (P = .0007). Compared to intra-operative radiographs, PDH and FH decreased at latest post-operative phase for ALIF (P < .03), LLIF (P < .003), TLIF (P < .001), and PLIF (P < .005). SL decreased for ALIF (P = .0008), and TLIF (P = .02). LL did not change postoperatively across techniques. Patient reported outcomes improved post-surgically and disability index decreased, but neither differed between techniques. CONCLUSION: LIF, regardless of technique, was shown to provide significant radiographic changes in PDH and FH. Techniques utilizing larger intervertebral cage sizes (ALIF/LLIF) improved SL. Single level LIF did not affect overall LL. No single technique displayed superior radiographic robustness over time.

Early versus Standard Weight Bearing Following Operative Treatment of Tibial Plateau Fractures: Do We Really Have to Wait So Long?

Postoperative management of tibial plateau fractures classically involves a prolonged period between 10 and 12 weeks of nonweight bearing or partial weight bearing. In recent years, there has been some support for earlier weight-bearing protocols although this remains controversial. The goal of this study was to investigate the difference in outcomes between early weight-bearing (EWB) and traditional weight-bearing (TWB) protocols. This investigation is a retrospective review of 92 patients treated with open reduction and internal fixation of tibial plateau fractures at a single institution, from August 2018 to September 2020. Subjects were divided into EWB (< 10 weeks) and traditional nonweight bearing groups (≥ 10 weeks). Key outcome measures collected include injury classification, mechanism of injury, surgical fixation method, bone grafting, time to full weight bearing, radiographic time to union, range-of-motion, all-cause complications, and subsidence at an average follow-up time of 1 year. The EWB group had an earlier average time to weight bearing versus the TWB group (6.5 ± 1.4 vs. 11.8 ± 2.3 weeks, p < 0.0001). There was no difference in the classification of fractures treated between the two groups, with Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association B3 fractures the most common in the EWB group, and C3 fractures the most common in the TWB group. Radiographic time to union was no different between the two groups (93.5 ± 53.7 days for EWB vs. 103.7 ± 77.6 days for TWB, p = 0.49). There was no significant difference in complication rates or subsidence. Following operative treatment of tibial plateau fractures, patients who underwent a weight-bearing protocol earlier than 10 weeks were able to recover faster with similar outcomes and complications compared with patients who started weight bearing after 10 weeks or more. LEVEL OF EVIDENCE: III.

Does a delay to surgery for preoperative echocardiogram affect outcomes in patients with hip fracture?

Introduction: Delay to surgery >24 hours has been shown to correlate with mortality rates in patients with hip fracture when left untreated. Many of these patients have multiple comorbidities, including aortic stenosis (AS), and undergo workup for operative clearance, which may delay time to surgery. The purpose of this study was to examine whether preoperative echocardiogram workup affects time to surgery, complications, and mortality after operative fixation for hip fracture. Methods: Our institutional hip fracture registry was retrospectively reviewed for inclusion over a 3-year period. Patients who had a preoperative echocardiogram (yECHO) for operative clearance were compared with those who did not (nECHO). Demographic data, time to surgery, overall complication rate, and mortality at 30 days, 90 days, and 1 year were collected. Results: Two cohorts consisted of 136 yECHO patients (45.8%) and 161 nECHO patients (54.2%). Thirty-two yECHO patients (23.5%) had AS. Patients in the yECHO cohort were more likely to have a complication for any cause compared with nECHO patients (25.7% vs. 10.6%, P = 0.01) and have a higher mortality rate at 1 year (38.9% vs. 17.4%, P = 0.001). There was no association found between AS and all-cause complication (P = 0.54) or 30-day (P = 0.13) or 90-day mortality rates (P = 0.79). However, patients with AS had a significantly higher mortality rate at 1 year (45.8% vs. 25.1%, P = 0.03). Conclusion: This study reinforces the benefits of ensuring less than a 24-hour time to surgery in the setting of a hip fracture and identifies an area of preoperative management that can be further optimized to prevent unnecessary prolongation in time to surgery. Patients with known aortic stenosis are not associated with increased 30-day or 90-day mortality or all-cause complications. Surgical delays in the yECHO cohort were attributed to preoperative medical assessments, including echocardiograms and the management of comorbidities. Therefore, the selective utilization of preoperative echocardiograms is needed and should be reserved to ensure they have a definitive role in guiding the perioperative care of patients with hip fracture. Level of Evidence: III.

Intramedullary Fixation Versus Plate Fixation of Distal Fibular Fractures: A Systematic Review.

INTRODUCTION: The purpose of this systematic review and meta-analysis was to provide an update of the recent literature comparing clinical outcomes of surgically treated fibular fractures using intramedullary nailing (IMN) with open reduction and internal plate fixation (ORIF). METHODS: A literature search reporting clinical outcomes after IMN or ORIF of the distal fibula was conducted on PubMed. Inclusion criteria consisted of original studies; studies focusing on clinical outcomes after IMN or IMN and ORIF published before May 11, 2022; studies with at least 5 patients; and studies reporting union rates, complication rates, and patient-reported outcomes such as American Orthopaedic Foot and Ankle Society (AOFAS) and Olerud-Molander scores. RESULTS: Of 2,394 studies identified, a total of 29 studies (4 LOE-I, 2 LOE-II, 6 LOE-III, 17 LOE-IV) were included consisting of 1,850 IMN patients and 514 plate patients. The pooled mean age of IMN patients was 58 years (95% confidence interval [CI], 54 to 62, I2 = 42%) versus 57 years (95% CI, 53 to 62, I2 = 49%) in ORIF. Union rates for IMN patients revealed a 99% union rate (95% CI, 0.98 to 1.00, I2 = 20%) versus 97% union rate for ORIF patients (95% CI, 0.94 to 0.99, I2 = 0%). Studies that compared IMN with ORIF revealed no difference in union rates (risk ratio [RR] = 0.99, 95% CI, 0.96 to 1.02, I2 = 0%). IMN patients showed a 15% complication rate (95% CI, 0.09 to 0.23, I2 = 89%), whereas plate patients had a complication rate of 30% (95% CI, 0.18 to 0.46, I2 = 63%). When comparing studies with both treatments, IMN patients had a significantly lower risk of complications (RR = 0.49, 95% CI, 0.29 to 0.82, I2 = 50%). The IMN group trended toward a higher mean AOFAS and Olerud-Molander score than the plate group by 4.53 (95% CI, -14.58 to 23.65, I2 = 85%) and 3.54 (95% CI, -2.32 to 9.41, I2 = 76%) points, respectively. CONCLUSION: Current literature reveals near equivalence in union rates and a markedly lower risk of complications when comparing IMN with plate fixation. While IMN patients had higher AOFAS and Olerud-Molander scores, these differences were not statistically significant. Notably, subgroup analyses indicated that rates of symptomatic implant and removal of implant were comparable between IMN and ORIF, which may indicate that wound-related complications were reduced in the minimally invasive IMN technique. While the high cost of IMN implants remains a barrier to their widespread adoption, the long-term benefits of reducing complications, specifically associated with wound complications in high-risk populations, may greatly improve quality of care for patients with distal fibula fractures. Additional research and cost-effectiveness analyses are warranted to fully assess the long-term benefits and economic feasibility of using IMN fixation for distal fibula fractures. LEVEL OF EVIDENCE: Therapeutic Level IV.

Pediatric Gender Diversity Beyond the Binary: An Exploration of Gender-Affirming Care for Nonbinary and Genderqueer Youth Seen Over Time at a Single Institution Gender Center.

Purpose: The nonbinary and genderqueer (NBGQ) youth population is growing, yet scant research focuses on this distinct group. We aim to gain a deeper understanding of desired gender-affirming care and interventions pursued by NBGQ youth. Methods: A retrospective chart review of NBGQ patients seen at the University of California, San Francisco Child and Adolescent Gender Center from January 1, 2009, to December 31, 2020, was performed. Demographic information, desired gender-affirming care, and gender-affirming interventions pursued at initial and most recent visits were collected. Results: Initial visit charts of 116 NBGQ youth who attended more than one clinic visit were reviewed. In total, 48 unique genders were documented; gender evolved over time for some youth, as did desired gender-affirming care. At the most recent visit, 15 youth (12.9%) had a binary gender, and 101 youth (87.1%) had an NBGQ gender. At the initial visit, 56 youth (48.3%) were interested in gender-affirming hormone therapy, compared with 75 youth (65.6%) at the most recent visit. In addition, 21 (18.1%) and 49 (42.2%) youth were interested in surgery at the initial and most recent visits, respectively. In general, interest in interventions was higher than pursuit of interventions. Conclusion: There is vast diversity of gender and differences in desired gender-affirming care within the NBGQ youth population. Desires for gender-affirming care within the cohort changed over time, and not all those who expressed a desire for an intervention received it. The reasons are likely multifactorial, highlighting the need for expectation-free and patient-specific affirming care and research on the NBGQ youth population, while also considering barriers to care.

Comparative outcomes after treatment of peri-implant, periprosthetic, and interprosthetic femur fractures: which factors increase mortality risk?

Objectives: To compare mortality rates between patients treated surgically for periprosthetic fractures (PPF) after total hip arthroplasty (THA), total knee arthroplasty (TKA), peri-implant (PI), and interprosthetic (IP) fractures while identifying risk factors associated with mortality following PPF. Design: Retrospective. Setting: Single, Level II Trauma Center. Patients/Participants: A retrospective review was conducted of 129 consecutive patients treated surgically for fractures around a pre-existing prosthesis or implant from 2013 to 2020. Patients were separated into 4 comparison groups: THA, TKA, PI, and IP fractures. Intervention: Revision implant or arthroplasty, open reduction and internal fixation (ORIF), intramedullary nailing (IMN), percutaneous screws, or a combination of techniques. Main Outcome Measurements: Primary outcome measures include mortality rates of different types of PPF, PI, and IP fractures at 1-month, 3-month, 6-month, 1-year, and 2-year postoperative. We analyzed risk factors associated with mortality aimed to determine whether treatment type affects mortality. Results: One hundred twenty-nine patients were included for final analysis. Average follow-up was similar between all groups. The overall 1-year mortality rate was 1 month (5%), 3 months (12%), 6 months (13%), 1 year (15%), and 2 years (22%). There were no differences in mortality rates between each group at 30 days, 90 days, 6 months, 1 year, and 2 years (P-value = 0.86). A Kaplan-Meier survival curve demonstrated no difference in survivorship up to 2 years. Older than 65 years, history of hypothyroidism and dementia, and discharge to a skilled nursing facility (SNF) led to increased mortality. There was no survival benefit in treating patients with PPFs with either revision, ORIF, IMN, or a combination of techniques. Conclusion: The overall mortality rates observed were 1 month (5%), 3 months (12%), 6 months (13%), 1 year (15%), and 2 years (22%), and no differences were found between each group at all follow-up time points. Patients aged 65 and older with a history of hypothyroidism and/or dementia discharged to an SNF are at increased risk for mortality. From a mortality perspective, surgeons should not hesitate to choose the surgical treatment they feel most comfortable performing. Level of Evidence: Level III.