Principles for management of hip fracture for older adults taking direct oral anticoagulants: an international consensus statement

Hip fracture is a common serious injury among older adults, yet the management of hip fractures for patients taking direct oral anticoagulants remains inconsistent worldwide. Drawing from a synthesis of available evidence and expert opinion, best practice approaches for managing patients with a hip fracture and who are taking direct oral anticoagulants pre-operatively were considered by a working group of the Fragility Fracture Network Hip Fracture Audit Special Interest Group. The literature and related clinical guidelines were reviewed and a two-round modified Delphi study was conducted with a panel of experts from 16 countries and involved seven clinical specialities. Four consensus statements were achieved: peripheral nerve blocks can reasonably be performed on presentation for patients with hip fracture who are receiving direct oral anticoagulants; hip fracture surgery can reasonably be performed for patients taking direct oral anticoagulants < 36 h from last dose; general anaesthesia could reasonably be administered for patients with hip fracture and who are taking direct oral anticoagulants < 36 h from last dose (assuming eGFR > 60 ml.min-1.1.73 m-2); and it is generally reasonable to consider recommencing direct oral anticoagulants (considering blood loss and haemoglobin) < 48 h after hip fracture surgery. No consensus was achieved regarding timing of spinal anaesthesia. The consensus statements were developed to aid clinicians in their decision-making and to reduce practice variations in the management of patients with hip fracture and who are taking direct oral anticoagulants. Each statement will need to be considered specific to each individual patient's treatment.

Fractional Lengthening of Forearm Flexor Tendons: A Cadaveric Biomechanical Analysis

PURPOSE

Multiple procedures have been described for wrist and finger flexion contractures and spasticity. Fractional lengthening of forearm flexor tendons involves making parallel transverse tenotomies at the musculotendinous junction to elongate the muscle. Currently, there is limited literature to define the biomechanical consequences of this lengthening technique.

METHODS

Forty-eight flexor tendons were harvested from eight paired upper limbs including flexor carpi radialis, flexor carpi ulnaris, flexor pollicis longus, and flexor digitorum superficialis tendons. Each tendon that was lengthened was paired with the contralateral tendon as a control. A pair of transverse tenotomies were completed for the fractional lengthening. The first tenotomy was performed at the musculotendinous junction where the tendon narrowed to 75% of its maximal width. The second tenotomy was made 1 cm distal to the first. Tendon length was measured before and after fractional lengthening at a constant resting tension of 1 N. The maximum load at failure of each tendon and the mechanism of failure were each measured and compared with the contralateral side.

RESULTS

After fractional lengthening, the mean increase in resting tendon length was 4 mm. When loaded to failure, the mean maximum load of fractionally lengthened tendons was 42% of the mean maximum load of intact tendons. All lengthened tendons failed at the distal tenotomy site.

CONCLUSIONS

Fractional lengthening resulted in an increase of 3-6 mm (mean: 4 mm) in tendon length at resting tension. There was a significant loss in tensile strength and load to failure following fractional lengthening compared with an intact musculotendinous unit.

CLINICAL RELEVANCE

The reduction in tensile strength following fractional lengthening results in loads at failure that are, in some cases, lower than the estimated forces required to perform basic tasks. Caution during the healing and rehabilitation period is warranted.

Biomechanical Analysis of Headless Compression Screw Versus Tension Band Wiring for Proximal Interphalangeal Joint Arthrodesis

PURPOSE

Proximal interphalangeal (PIP) joint arthrodesis is a procedure employed to address arthritis, instability, and deformity. Multiple fixation methods are available to maintain stability across the arthrodesis interval, including headless compression screws (HCSs), tension band wiring (TBW), plating, and Kirschner wire constructs. The purpose of this study was to compare the biomechanical properties of the HCS and TBW techniques.

METHODS

Thirty-two nonthumb digits from the paired upper limbs of four fresh frozen cadavers were divided into pairs, matching contralateral digits from the same specimen. One PIP joint of each pair was fused with an antegrade 3.5 mm HCS, and the second was fused with TBW using 0.035 in. Kirschner wires with 24-gauge dental wire. Each construct was then stressed to 10 N in the radial deviation, ulnar deviation, flexion, and extension planes, and stiffness (N/mm) was calculated. The fingers were stressed to failure in extension with the ultimate load and mode of failure recorded.

RESULTS

When stressed in extension, the HCS construct had a significantly greater mean stiffness than the TBW construct (16.4 N/mm vs 10.8 N/mm). The stiffness in all other planes of motion were similar between the two constructs. The mean ultimate load to failure in extension was 91.4 N for the HCS and 41.9 N for the TBW. The most common mode of failure was fracture of the dorsal lip of the proximal phalanx (13/16) for the HCS and bending of the K-wires (15/16) for TBW.

CONCLUSIONS

Arthrodesis of the PIP joint using a HCS resulted in a construct that was significantly stiffer in extension with greater than double the load to failure compared to TBW.

CLINICAL RELEVANCE

Although the stiffness required to achieve successful PIP joint arthrodesis has not been well quantified, the HCS proved to be the most favorable construct with respect to initial strength and stability.

Disease burden of bacteraemia with extended-spectrum beta-lactamase-producing and carbapenem-resistant Enterobacterales in Korea

BACKGROUND

Despite the significant impact of multi-drug-resistant bacteraemia, especially extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E) and carbapenem-resistant Enterobacterales (CRE), the burden of disease has not been investigated thoroughly.

AIM

To evaluate the clinical outcomes and socio-economic burden of ESBL-E and CRE bacteraemia nationwide in the Republic of Korea.

METHODS

A search was undertaken for all cases of ESBL-E and CRE bacteraemia and matched controls in 10 hospitals in the Republic of Korea over 6 months. Patients with ESBL-E or CRE bacteraemia were classified as the R group, and matched controls with antibiotic-susceptible bacteraemia and without infection were classified as the S and N groups, respectively. Patients' clinical data were collected, and the economic burden was estimated based on medical expenses, loss of productivity and total costs.

FINDINGS

In total, 795 patients were identified, including 265 patients with ESBL-E or CRE bacteraemia and their matched controls. The mean total length of stay for patients with ESBL-E and CRE in the R group was 1.53 and 1.90 times that of patients in the S group, respectively. The 90-day mortality rates for ESBL-E in the R and S groups were 12.1% and 5.6%, respectively, and the corresponding figures for CRE were 28.6% and 12.0%. There were significant differences in the total costs between the R, S and N groups for both ESBL-E and CRE (ESBL-E: $11,151 vs $8712 vs $6063, P=0.004; CRE: $40,464 vs $8748 vs $7279, P=0.024).

CONCLUSION

The clinical and economic burden imposed by ESBL-E or CRE bacteraemia was extremely high. These findings suggest that efforts to control resistant bacteraemia are necessary to reduce this burden.

Association between Hashimoto's thyroiditis and melanoma: a retrospective matched cohort study

An inflammatory microenvironment has been shown to increase risk for malignant melanoma, suggesting that melanoma may be related to a pro-inflammatory state. Though Hashimoto's thyroiditis is one of the most common autoimmune diseases, there are no investigations of its relationship with melanoma. We aim to determine if Hashimoto's increases risk of developing melanoma. A retrospective, validated cohort of patients with a diagnosis of Hashimoto's between 2005 and 2020 were identified using the Olmsted County database. Patients were age and sex matched to controls without a Hashimoto's diagnosis. The primary outcomes were development of melanoma and time to first melanoma diagnosis. 4805 patients were included in the study, with 1726 (36%) having a diagnosis of Hashimoto's. Hashimoto's patients had no significant difference in risk of melanoma (relative risk 0.96, 95% CI 0.78-1.17) or nonmelanoma skin cancer (relative risk 0.95, 95% CI 0.86-1.06) compared with matched controls. This suggests that the local proinflammatory environment present in Hashimoto's does not contribute significantly to melanoma risk. Larger studies may be needed to further characterize the relationship between these diseases.

Evaluation of Radiographic Parameters Following Dorsal Wrist-Spanning Plate Fixation of Distal Radius Fractures to the Second Versus Third Metacarpal

PURPOSE

Dorsal wrist-spanning plate fixation for comminuted, intra-articular distal radius fractures involves the indirect reduction of intra-articular fractures via ligamentotaxis. The reduction is maintained by application of a bridge plate from the radial diaphysis to either the second or third metacarpal. The objective of this study was to retrospectively compare radiographic outcomes between distal radius fractures managed with bridge plate fixation to the second versus third metacarpal.

METHODS

A single-institution retrospective review identified 50 cases of distal radius fractures that underwent dorsal wrist-spanning plate fixation, with 9 and 41 fractures undergoing fixation to the second and third metacarpals, respectively. Radiographic parameters, such as radial height, radial inclination, volar tilt, and ulnar variance, were measured at 3 time points: immediately after surgery, immediately prior to elective plate removal, and at the final follow-up. Radiographic measurements of the 2 cohorts were compared at the 3 time points.

RESULTS

Final radiographs showed an average radial height of 8.9 mm versus 9.4 mm for the second versus third metacarpal cohorts, respectively; average radial inclination of 17.4° for both the second and third metacarpal cohorts; average volar tilt of 1.9° versus 1.7° for the second versus third metacarpal cohorts, respectively; and an average ulnar variance of +0.6 mm versus +0.1 mm for the second versus third metacarpal cohorts, respectively. Radiographic parameters of the second and third metacarpal cohorts were similar across all the time points. Additionally, evaluation of the radiographic parameters across the 3 time points (immediately after surgery, immediately prior to elective plate removal, and at the final follow-up) demonstrated little to no loss of radiographic alignment.

CONCLUSIONS

Radiographic outcomes for distal radius fractures managed with bridge plate fixation to the second versus third metacarpal appear similar. The distal plate fixation site can likely be determined on the basis of fracture anatomy and patient-specific features.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Sub-1.4 cm3 capsule for detecting labile inflammatory biomarkers in situ

Transient molecules in the gastrointestinal tract such as nitric oxide and hydrogen sulfide are key signals and mediators of inflammation. Owing to their highly reactive nature and extremely short lifetime in the body, these molecules are difficult to detect. Here we develop a miniaturized device that integrates genetically engineered probiotic biosensors with a custom-designed photodetector and readout chip to track these molecules in the gastrointestinal tract. Leveraging the molecular specificity of living sensors1, we genetically encoded bacteria to respond to inflammation-associated molecules by producing luminescence. Low-power electronic readout circuits2 integrated into the device convert the light emitted by the encapsulated bacteria to a wireless signal. We demonstrate in vivo biosensor monitoring in the gastrointestinal tract of small and large animal models and the integration of all components into a sub-1.4 cm3 form factor that is compatible with ingestion and capable of supporting wireless communication. With this device, diseases such as inflammatory bowel disease could be diagnosed earlier than is currently possible, and disease progression could be more accurately tracked. The wireless detection of short-lived, disease-associated molecules with our device could also support timely communication between patients and caregivers, as well as remote personalized care.

Acute Lower Extremity Fracture Management in Chronic Spinal Cord Injury: 2022 Delphi Consensus Recommendations

Our objective was to develop a clinical practice guideline (CPG) for the treatment of acute lower extremity fractures in persons with a chronic spinal cord injury (SCI).

METHODS

Information from a previous systematic review that addressed lower extremity fracture care in persons with an SCI as well as information from interviews of physical and occupational therapists, searches of the literature, and expert opinion were used to develop this CPG. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to determine the quality of evidence and the strength of the recommendations. An overall GRADE quality rating was applied to the evidence.

CONCLUSIONS

Individuals with a chronic SCI who sustain an acute lower extremity fracture should be provided with education regarding the risks and benefits of operative and nonoperative management, and shared decision-making for acute fracture management should be used. Nonoperative management historically has been the default preference; however, with the advent of greater patient independence, improved surgical techniques, and advanced therapeutics and rehabilitation, increased use of surgical management should be considered. Physical therapists, kinesiotherapists, and/or occupational therapists should assess equipment needs, skills training, and caregiver assistance due to changes in mobility resulting from a lower extremity fracture. Therapists should be involved in fracture management as soon as possible following fracture identification. Pressure injuries, compartment syndrome, heterotopic ossification, nonunion, malunion, thromboembolism, pain, and autonomic dysreflexia are fracture-related complications that clinicians caring for patients who have an SCI and a lower extremity fracture may encounter. Strategies for their treatment are discussed. The underlying goal is to return the patient as closely as possible to their pre-fracture functional level with operative or nonoperative management.

External validation of the biomarker based ABCD score in atrial fibrillation patients with a non gender CHA2DS2 VASc score 0 to 1, A Korean multicenter retrospective cohort

Background

Patients with low to intermediate risk atrial fibrillation (AF), defined as non-gender CHA2DS2-VASc score of 0–1, are still at risk of stroke. This study verified the usefulness of ABCD score (Age [≥60 years], B-type natriuretic peptide [BNP] or N-terminal pro-BNP [≥300 pg/ml], Creatinine clearance [&lt;50 ml/min/1.73 m2], and Dimension of the left atrium [≥45 mm]) for stroke risk stratification in non-gender CHA2DS2-VASc score 0–1.

Methods

This multi-center cohort study retrospectively analyzed AF patients with non-gender CHA2DS2-VASc score 0–1. The primary endpoint was the incidence of stroke with or without anti-thrombotic treatment (ATT). An ABCD score was also validated.

Results

Overall, 2694 patients (56.3±9.5 years; female, 726 [26.9%]) were followed-up for 4.0±2.8 years. The overall stroke rate was 0.84/100 person-years (P-Y), stratified as follows: 0.46/100P-Y for an ABCD score 0; 1.02/100P-Y for an ABCD score≥1. The ABCD score was superior to the non-gender CHA2DS2-VASc score in stroke risk stratification (C-index=0.618, P=0.015; net reclassification improvement=0.576, P=0.040; integrated differential improvement=0.033, P=0.066). ATT was prescribed in 2353 patients (86.5%), and the stroke rate was significantly lower in patients receiving non-vitamin K antagonist oral anticoagulant (NOAC) therapy and an ABCD score≥1 than in those without ATT (0.44/100P-Y versus 1.55/100 P-Y; hazard ratio=0.26, 95% confidence interval 0.11–0.63, P=0.003).

Conclusion

The biomarker-based ABCD score demonstrated improved stroke risk stratification in AF patients with non-gender CHA2DS2-VASc score 0–1. Furthermore, NOAC with an ABCD score≥1 was associated with significantly lower stroke rate in AF patients with a non-gender CHA2DS2-VASc score 0–1.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Korean Disease Control and Prevention Agency

Clinical and radiological outcome of the locked plate osteosynthesis in distal metadiaphyseal tibial fracture according to the severity of comminution: Varus reduction would not be preferable with lower clinical outcomes

BACKGROUND

The optimal treatment for distal tibial fractures remains a matter of debate. Nonetheless, plate osteosynthesis produces favorable results to intramedullary stabilization in aspects of alignment restoration.

AIM

The aim of the study was to compare the radiologic and clinical outcomes of distal metadiaphyseal tibial fracture between a simple/wedge fracture (SWF) and a comminuted fracture (CF) using minimally invasive plate osteosynthesis (MIPO).

PATIENTS AND METHODS

This retrospective study analyzed patients with SWF or CF of the distal tibial metadiaphysis that was surgically treated with a locking compression plate. Postoperative radiographic assessments and the time to radiologic union were noted. Clinical assessments were evaluated using both the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and the foot function index (FFI). Postoperative complications were documented.

RESULTS

Seventy-one cases were analyzed over a mean follow-up period of 20.9 months. Thirty-six patients had SWF and 35 patients presented with CF. The mean time to radiologic union, amounts of postoperative coronal angulation, and incidence of malunion showed no statistical differences. Fibular fixation was more applied in the CF group (P < 0.001). Moreover, the clinical scores revealed no differences. Nonetheless, in the valgus union group, the AOFAS ankle-hindfoot score was 90.9 compared to 84.1 in the varus union group (P = 0.042) and the FFI was 9.2% compared to 20.2% in the varus union group (P = 0.017).

CONCLUSION

Plate osteosynthesis for SWF or CF of the distal tibial metadiaphysis led to high union rates and good clinical outcomes. There was no significant difference in the radiologic and clinical results according to the presence of fracture comminution. Nonetheless, the valgus union group showed better clinical outcomes than the varus union group. Clinically, it would be preferred to avoid intraoperative varus reduction.

Amputation and infection are the greatest fears in patients with diabetes foot complications

AIMS

To determine the degree patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations fear complications (death, dialysis, heart attack, stroke, blindness, diabetic foot infection, minor and major lower extremity amputation [LEA]) that can occur and to assess if there is a difference between fears of patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations and diabetic patients without these complications.

METHODS

478 patients completed an eight question Likert scale survey. The study group was defined as non-infected foot ulcers, neuropathic fractures and Charcot neuroarthropathy.

RESULTS

Of the 478 patients, 121 (25.3 %) had diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations and 357 (74.7 %) did not. The study group had significantly higher odds of reporting extreme fear of foot infection (OR 2.8, 95 % CI 1.8-4.5), major LEA (OR 2.8, 95 % CI 1.8-4.4), minor LEA (OR 2.3, 95 % CI 1.5-3.5), blindness (OR 2.0, 95 % CI 1.3-3.2), dialysis (OR 2.0, 95 % CI 1.1-3.3), and death (OR 2.4, 95 % CI 1.4-4.2). In the study group highest rated fear measures were foot infection (3.71, SD 1.23), minor amputation (3.67, SD 1.45) and major amputation (3.63, SD 1.52). There were no significant differences in the mean fear of infection, minor amputation or major amputation.

CONCLUSION

Patients with diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations reported higher fear ratings of diabetes-related complications compared to those without these complications.

Effect of Sensory Neuropathy on the Predictive Value of Inflammatory Biomarkers for Osteomyelitis in Diabetic and Nondiabetic Patients with Foot Infections

OBJECTIVE

To investigate the predictive value of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in persons with and without diabetes with osteomyelitis (OM).

METHODS

We evaluated 455 patients in a retrospective cohort study of patients admitted to the hospital with diabetic foot OM (n = 177), diabetic foot soft-tissue infections (STIs) (n = 176), nondiabetic OM (n = 51), and nondiabetic STIs (n = 51). Infection diagnosis was determined through bone culture, histopathologic examination for OM, and/or imaging (magnetic resonance imaging/single-photon emission computed tomography) for STI. The optimal cutoff values of ESR and CRP in predicting OM were determined by receiver operating characteristic curve analysis. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were determined through contingency tables.

RESULTS

In persons without diabetes with STI or OM, the mean ESR and CRP differences were 10.0 mm/h and 2.6 mg/dL, respectively. In contrast, persons with diabetes had higher levels of each: 24.8 mm/h and 6.8 mg/dL, respectively. As a result, ESR and CRP predicted OM better in patients with diabetes. However, when patients were stratified by neuropathy status, ESR remained predictive of OM in diabetic patients with neuropathy (75% sensitivity, 58% specificity) but not in diabetic patients without neuropathy (50% sensitivity, 44% specificity). Also, CRP remained predictive irrespective of neuropathy status. A similar trend was observed in patients without diabetes.

CONCLUSIONS

Previous studies have reported that ESR and CRP are predictive of OM. However, this study suggests that neuropathy influences the predictive value of inflammatory biomarkers. The underlying mechanisms require further study.

The Impact of Hospitalization for Diabetic Foot Infection on Health-Related Quality of Life: Utilizing PROMIS

Diabetic foot infections (DFI) are an increasingly common cause of hospitalizations. Once hospitalized with DFI, many patients require some level of amputation, often undergoing multiple operations. With increasing importance on patient-centered metrics, self-reported health-related quality of life (HRQOL) tools have been developed. This prospective cohort study aimed assessed the impact of DFI on HRQOL. Two hundred twenty-four patients completed the 29-item Patient-Reported Outcome Measurement Information System (PROMIS) and 12-Item Short Form (SF-12) survey. Secondary outcomes using the Foot and Ankle Ability Measures survey were obtained and included in the analysis. The study group was comprised of hospitalized patients with DFIs (n = 120), and the control group was comprised of patients with diabetes who were evaluated for routine outpatient foot care (n = 104); diabetic foot screening, wound care, onychomycosis, and/or callosities. Using this cohort, a propensity score-matched sample of hospitalized patients with DFI (n = 35) and control group patients (n = 35) was created for comparative analysis. The 2-independent sample t test was used to test for group differences on each of the PROMIS subscale outcomes. Using PROMIS, we found that hospitalized patients with DFI reported significantly worse HRQOL in 6 of 7 subscales (physical function, anxiety, depression, fatigue, social role, pain intensity; p value range: .0001-.02) compared to outpatients with diabetes evaluated for routine foot care. There was no significant difference between the 2 groups on sleep disturbance (p = .22). Patients hospitalized for DFI report lower HRQOL compared to patients with diabetes receiving routine outpatient foot care.

Effect of Smoking on Short-term Postoperative Complications After Elective Upper Extremity Surgery

Background: There is a paucity of literature exploring the impact of smoking on short-term complications, readmissions, and reoperations after elective upper extremity surgery using a large multicenter national database. We hypothesized that smokers will have an increased rate of complications, readmissions, and reoperations compared with a cohort of nonsmokers undergoing elective upper extremity surgery. Methods: Patient data were collected from the American College of Surgeons National Surgical Quality Improvement Program database between the years 2012 and 2017. Patients were included if they underwent elective surgery of the upper extremity using 338 predetermined Current Procedural Terminology codes. The data collected were divided into patient demographics, comorbidities, perioperative variables, and 30-day complications. Current smoking status was defined as smoking within 1 year prior to surgery. The incidence of surgical complications, reoperations, and readmissions was compared between the 2 cohorts using multivariable regression analysis. Results: Of the 107 943 patients undergoing elective surgeries of the upper extremity, 73 806 met the inclusion criteria. Of these, 57 986 (78.6%) were nonsmokers in the year prior to surgery, and 15 820 (21.4%) were current smokers. Between these groups, current smokers were younger (P < .001), more often men (P < .001), had lower body mass index (P < .001), and more often underwent procedures that involved bone manipulation (P < .001). Multivariate regression analysis defined current smoking as significantly associated with overall surgical site complications, superficial surgical site infections, deep surgical site infections, reoperation, and readmission. Conclusion: Current smoking was significantly associated with an increase in all surgical site complications, readmissions, and reoperations after elective upper extremity surgery. Surgeons should consider smoking a modifiable risk factor for postoperative complications and appropriately counsel patients on outcomes and complications given the elective nature of upper extremity surgery.

Risk Factors and Reasons for Emergency Department Visits Within 30 Days of Elective Hand Surgery: An Analysis of 3,261 Patients

Background: The frequency of hand and elbow surgeries occurring in outpatient and elective settings is on the rise. Emergency department (ED) visits in the postoperative period are increasingly used as quality measures for surgical care. The aim of this study is to determine the number of postoperative ED visits, the primary reason for these visits, and to identify risk factors associated with these visits. Methods: We examined all elective hand and elbow procedures performed at two hospitals within a single healthcare network between 2008 and 2017. A total of 3,261 patients met the study criteria. Descriptive statistics were calculated for our population, followed by univariate and multivariate analyses, to identify risk and protective factors associated with ED visits in the first 30 days after surgery. Results: Eighty-seven of 3,261 patients presented to the ED within 30 days of their operation (2.7%). The most common reasons for ED visits were related to pain (28.7%), swelling (26.4%), and concerns for infection (20.7%). Univariate analysis indicated history of drug use, number of procedures, smoking history, and serum albumin <3.5 mg/dL as risk factors for returns to the ED. Multivariate analysis identified history of drug use, number of procedures, and serum albumin <3.5 mg/dL as independent risk factors. Smoking history failed to achieve statistical significance as an independent risk factor. Both univariate and multivariate analyses identified age >60 years as protective for postoperative ED visits. Conclusions: ED visits within the first 30 days after elective hand surgery are relatively common, despite remarkably low complication rates among these procedures. This information may help to improve risk stratification in these patients, and to aid in the development of enhanced postoperative follow-up strategies to reduce unnecessary utilization of emergency medical services. Level of Evidence: Level III (Therapeutic).

Are Readmission and Reoperation Rates for Lower Extremity Necrotizing Fasciitis Different Between Patients With and Without Diabetes Mellitus?

Necrotizing fasciitis is a condition associated with high morbidity and mortality unless emergent surgery is performed. This study aims to understand the hospital course of diabetic and nondiabetic patients managed for lower-extremity necrotizing fasciitis by identifying factors contributing to readmissions and reoperations. About 562 patients treated for lower-extremity necrotizing fasciitis were selected from the American College of Surgeons-National Surgical Quality Improvement Program database between 2012 and 2017. The unplanned reoperation and readmission rates for all patients during the 30-day postoperative period were 9.4% and 5.3%, respectively. Out of 562 patients with lower-extremity necrotizing fasciitis, 326 (58.0%) patients had diabetes. Diabetes patients were more likely to undergo amputation (p < .00001). Neither readmission (6.1% vs 4.2%, p = .411) nor reoperation (8.6% vs 10.6%, p = .482) were significantly different between patients with and without diabetes. Neither readmission (7.2% vs 4.0%, p = .159) nor reoperation (4.1% vs 3.7%, p = .842) were significantly different between patients undergoing amputation and nonamputation procedures. In simple logistic regression, factors associated with unplanned reoperation included poorer renal function, thrombocytopenia, longer duration of surgery, longer hospital length of stay, postoperative surgical site infection, postoperative respiratory distress, and postoperative septic shock. Body mass index >30 kg/m² was associated with decreased odds of readmission. In multiple logistic regression, surgical site infection was the only predictor of reoperation (adjusted odds ratio 7.32, 95% confidence interval 2.76-19.1), and any amputation was associated with readmission (adjusted odds ratio 4.53, 95% confidence interval 1.20-29.6). Further study is needed to understand patient characteristics to better direct management. However, the current study elucidates patient outcomes for a relatively rare condition.

Postoperative Pneumonia and Aspiration Pneumonia Following Elderly Hip Fractures

OBJECTIVES

The present study aimed to investigate the incidence of and risk factors for postoperative pneumonia and aspiration pneumonia after hip fracture surgery.

DESIGN

Retrospective cohort study from 2005 to 2021.

SETTING

Asan Medical Center in Seoul, Republic of Korea.

PARTICIPANTS

A total 1,208 patients aged ≥ 65 years who underwent hip fracture surgery.

MEASUREMENTS

Postoperative pneumonia was defined as cases with new infiltration on chest x-ray or chest computed tomography (CT) after surgery or confirmed by a pulmonologist's consultation and diagnosis. Aspiration pneumonia was defined as: 1) radiologic findings of hospital-acquired pneumonia on chest radiographs or CT, medical record of aspiration pneumonia confirmed by a pulmonologist's consultation, and history of vomiting or aspiration, or 2) gravity-dependent opacity on chest CT when the history of vomiting or aspiration is ambiguous. Patient demographics, past medical history, pre-injury Koval score, Charlson Comorbidity Index (CCI), blood test results, length of hospital stay, and in-hospital mortality were evaluated. A comparison analysis and binary logistic regression were performed to identify the incidence and risk factors for postoperative pneumonia and aspiration pneumonia.

RESULTS

Postoperative pneumonia was diagnosed in 47 patients (3.9%), including 20 with aspiration pneumonia (1.7%). In the multivariate analysis, postoperative delirium (odds ratio [OR], 3.42; P < 0.001), American Society of Anesthesiologists (ASA) scores ≥ 3 (OR, 2.11; P = 0.021), and CCI (OR, 1.21; P = 0.013) were significant risk factors for postoperative pneumonia. Male sex (OR, 3.01; P = 0.017), postoperative delirium (OR, 3.16; P = 0.014), and preoperative serum albumin levels < 3.5 g/dL (OR, 7.00; P = 0.010) were significant risk factors for aspiration pneumonia.

CONCLUSION

ASA classification ≥ 3, higher CCI, and postoperative delirium were the risk factors for postoperative pneumonia. Male sex, postoperative delirium, and lower preoperative serum albumin level were the risk factors for aspiration pneumonia. Thus, physicians should pay attention to patients with the risk factors.

Effect of Diabetes and Hemoglobin A1c on Complications Following Elective Hand Surgery

Background: Limited research exists investigating the association between diabetes and glycemic control on complications following elective hand surgery. The goal of this research was to assess the incidence of complications within 30 days of elective hand surgery in a large population of diabetic patients compared to a population of non-diabetics. Furthermore, we sought to examine the relationship of glycemic control, as measured by HbA1c, and postoperative complications. Methods: We performed a retrospective review of electronic medical records at our institution of all patients who underwent elective hand, forearm, or elbow surgery from the dates of January 1^st, 2008 to December 31^st, 2017. Patients were categorized as diabetic or non-diabetic and most recent HbA1c was documented. Multivariable analysis was employed to compare the incidence of surgical complications within 30 days between the diabetics and non-diabetic populations, adjusting for baseline patient characteristics. Results: A total of 3,261 patients met the inclusion criteria. There were 646 (20%) diabetic patients and 2,615 (80%) non-diabetic patients. No difference was found in the overall rate of complications between the cohort of diabetic and non-diabetic patients. Additionally, statistical analysis found no difference in the complication rate between insulin and non-insulin controlled diabetics. Rates of complications were stratified based on HbA1c level and statistical analysis found no increased risk of complications with increased hemoglobin A1c value. Conclusions: In our present study we were not able to demonstrate any significant difference in the 30 day complication rates between and non-diabetics undergoing elective hand surgery. This study attempted to aid in risk stratification of diabetic patients by evaluating preoperative glycemic indices in the form of HbA1c.

Insulin Dependence Increases the Risk of 30-Day Postoperative Complications Following Ankle Fracture Surgery in Patients With Diabetes Mellitus

Patients with diabetes mellitus that undergo ankle fracture surgery have higher rates of postoperative complications compared to patients without diabetes mellitus. We evaluated the rate of complications in insulin-dependent diabetes mellitus patients, non-insulin-dependent diabetes mellitus patients, and patients without diabetes in the 30-day postoperative period following ankle fracture surgery. We also analyzed hospital length of stay, unplanned readmission, unplanned reoperation, and death. Patients who underwent operative management for ankle fractures between 2012 and 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program® database using Current Procedural Terminology codes. Multiple logistic regression was implemented. Adjusted odds ratios were calculated along with the 95% confidence interval. A total of 19,547 patients undergoing ankle surgery were identified from 2012 to 2016. Of these patients, 989 (5.06%) had insulin-dependent diabetes mellitus, 1256 (6.43%) had noninsulin-dependent diabetes mellitus, and 17,302 (88.51%) did not have diabetes mellitus. Compared to patients without diabetes, patients with insulin-dependent diabetes mellitus had significantly greater adjusted odds of superficial surgical site infections, deep surgical site infections, osteomyelitis, wound dehiscence, pneumonia, unplanned intubation, mechanical ventilation, urinary tract infection, cardiac arrest, bleeding requiring transfusion, sepsis, hospital length of stay, unplanned readmission, unplanned reoperation, and death following ankle fracture surgery. We demonstrate that insulin-dependent diabetes mellitus is a strong predictor of 30-day postoperative complications, unplanned readmission, unplanned reoperation, and death following ankle fracture surgery.

Postoperative Outcomes in Diabetic Pediatric Orthopaedic Surgery Patients: A National Database Study

BACKGROUND

Although the negative effects of diabetes mellitus (DM) on operative outcomes in orthopaedic surgery is a well-studied topic in adults, little is known about the impact of this disease in children undergoing orthopaedic procedures. This study aims to describe the postoperative complications in pediatric orthopaedic surgery patients with DM.

METHODS

Pediatric patients with insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) were retrospectively identified while selecting for elective orthopaedic surgery cases from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-Pediatric) database from 2012 to 2015. Univariate and multivariate analyses were performed to describe and assess outcomes when compared with nondiabetic patients undergoing similar procedures.

RESULTS

Of the 17,647 patients identified, 105 (0.60%) had DM. Of those 105 patients, 68 had IDDM and 37 had NIDDM. The median age of DM patients was 13.8 years (11.9 to 15.5 y) and 37.1% of all DM patients were male. Comparing DM to non-DM patients, no significant differences were noted in the overall complications (1.4% vs. 1.9%, P>0.05) or reoperation rates (1.2% vs. 1.9%, P>0.05); however, DM patients did have a higher occurrence of unplanned readmissions (4.8% vs. 1.7%; P=0.037). Diabetic patients were statistically more likely to have an unplanned readmission with 30 days (adjusted odds ratio=3.34; 95% confidence interval=1.21-9.24, P=0.021). when comparing IDDM to NIDDM, there was no significant difference in outcomes. Comparing NIDDM to non-DM patients, there was an increased incidence of nerve injury (5.6% vs. 0.18%; P=0.023), readmission rate (11.1% vs. 1.8%; P=0.043), and reoperation rate (11.1% vs. 1%; P=0.013) in nonspinal procedures and an increased incidence of pulmonary embolism (10% vs. 0%; P=0.002) in spinal arthrodesis procedures. NIDDM predicted longer hospital stays (adjusted odds ratio=1.49; 95% confidence interval=1.04, 2.14; P=0.028) compared with nondiabetic patients in extremity deformity procedures.

CONCLUSIONS

The 30-day complication, reoperation, and readmission rates for NIDDM patients were higher than that of non-DM patients. Furthermore, NIDDM is a predictor of longer hospital stays while DM is a predictor of unplanned readmissions. No statistical differences were noted when comparing outcomes of NIDDM to IDDM patients.

LEVEL OF EVIDENCE

Level III.

Systematic review and network meta-analysis of subscapularis management techniques in anatomic total shoulder arthroplasty

BACKGROUND

Controversy exists regarding the optimal subscapularis management technique in patients undergoing anatomic total shoulder arthroplasty. The purpose of this study was to compare clinical, radiographic, and functional outcomes between subscapularis tenotomy (ST), lesser tuberosity osteotomy (LTO), and subscapularis peel (SP) techniques.

METHODS

We performed a level III systematic review and network meta-analysis comparing ST, LTO, and SP in patients undergoing anatomic total shoulder arthroplasty. Our primary collection endpoints included range of motion, subscapularis function, subscapularis healing, functional patient-reported outcomes, complications, and revision surgery. Data were pooled and network meta-analysis was performed owing to the comparison of 3 groups.

RESULTS

Eight studies met our inclusion criteria for meta-analysis. There was no difference in sex or primary diagnosis between the 3 cohorts. No significant difference was found in postoperative external rotation or forward flexion between the groups. Meta-analysis found the SP cohort to have significantly greater internal rotation strength than the ST cohort. The belly-press test results were negative most commonly in the LTO group, and there was a significant difference compared with the ST or SP group (P < .0001). The weighted-mean healing rate for the LTO site was 98.9% on radiographic imaging. There was a significantly higher ultrasound healing rate in the LTO cohort than in the ST and SP cohorts. All groups had good postoperative patient-reported outcome scores (average American Shoulder and Elbow Surgeons score range, 78.6-87) and a relatively low rate of complications (3%).

CONCLUSION

This network meta-analysis demonstrates that the LTO group has superior healing and postoperative subscapularis-specific physical examination test results compared with the ST and SP groups. However, no difference in postoperative range of motion was found between the groups, and all techniques demonstrated good functional patient-reported outcomes, with a low rate of postoperative complications. These findings provide evidence-based support that ST, SP, and LTO all demonstrate similar outcomes; therefore, selection should be based on surgeon experience and comfort.

Short Term Radiographic and Patient Outcomes of a Biplanar Plating System for Triplanar Hallux Valgus Correction

Hallux valgus is a complex deformity with a variety of techniques described for correction. A biplanar plating system for triplanar correction system has been developed to address both the translation and rotational component of the hallux valgus deformity and allow an accelerated weightbearing protocol. The purpose of this study was to determine the correction and complications using radiographic parameters and patient reported outcomes. We sought to determine prognostic factors for successful correction, including age, gender, and preoperative deformity. From the medical records, we collected preoperative data. Patient-reported outcomes were obtained using AOFAS Hallux Metatarsophalangeal-Interphalangeal score, FAAM, and SF-12 scores preoperatively and postoperatively. Imaging was reviewed at preoperative and postoperative visits to determine hallux valgus angle, intermetatarsal angle, and tibial sesamoid position. Fifty-seven procedures, in 55 patients, were performed. There were 7 complications and mean follow-up time was 45.7 weeks (+ 28.3 weeks). Age over 62.5 years were associated with an increased risk of complications (p = .018). Males had an increased rate of complications (71%) compared with females. Radiographic parameters were significantly improved from preoperative values at alltime points (p < .05). Only the AOFAS Hallux Metatarsophalangeal-Interphalangeal score was statistically significant at 3, 6 and 12 months. We sought to determine the effectiveness of biplanar plating and triplanar correction procedure with early weightbearing. Over a 12 month follow-up period, our results showed significant improvement in deformity and maintained correction. AOFAS Hallux Metatarsophalangeal-Interphalangeal scores significantly improved from the preoperative to the postoperative state. Our results show a nonunion rate of 5.2%, which is comparable to prior studies.

Charcot Midfoot Reconstruction: Does Subtalar Arthrodesis or Medial Column Fixation Improve Outcomes?

Charcot neuroarthropathy is a complication of neuropathy often secondary to diabetes mellitus and most commonly affects the midfoot. In these patients, reconstruction of the foot may be required for limb salvage. A superconstruct technique has previously been described using intramedullary beaming fixation of the midfoot and hindfoot to span the zone of injury. Inclusion of the subtalar joint in the arthrodesis construct is not consistently performed among different surgeons. The aim of this study was to describe midfoot beaming constructs and postoperative complications after midfoot reconstruction with and without subtalar arthrodesis. We reviewed medical records of patients who underwent midfoot Charcot reconstruction with an intramedullary beaming superconstruct. Patients included in the study had at least 3 months of follow-up and had Sanders-Frykberg II/III classification of Charcot neuroarthropathy. Postoperative radiographs were evaluated for evidence of hardware failure at the latest follow-up evaluation. The main variables of interest were: hardware failure or nonunion requiring revision operation, deep infection, and unplanned reoperation. Thirty patients who underwent midfoot reconstruction were included. The mean follow-up was 67.4 ± 25.9 weeks. Twenty-two (73.3%) patients had concomitant subtalar arthrodesis and midfoot beaming. Overall complications were lower in patients with subtalar arthrodesis (40.9%) than those without subtalar arthrodesis (75%) resulting in an odds ratio of 0.271 (0.042-1.338, p = .146). Furthermore, increased number of screws used in the midfoot construct was negatively correlated with complications (r = -0.44, p = .01). An intramedullary midfoot beaming superconstruct with subtalar arthrodesis has previously been proposed to provide better fixation after midfoot beaming Charcot neuroarthropathy reconstruction. Our results suggest including the subtalar joint as part of a superconstruct for the reconstruction of Sanders-Frykberg II/III Charcot results in an 80% lower complication rate than intramedullary beaming alone. We also found an increased number of screws used in the midfoot results in a lower complication rate.

Insights into collateral susceptibility and collateral resistance in Acinetobacter baumannii during antimicrobial adaptation

The susceptibility of Acinetobacter baumannii exposed to primary antibiotic can be either increased or decreased when exposed to secondary antibiotic. This study was designed to assess the relative fitness, collateral susceptibility and collateral resistance of polymyxin B- (PMB-) adapted A. baumannii to ciprofloxacin (CIP), meropenem (MER), PMB, tetracycline (TET) and tobramycin (TOB). Strains of wild-type A. baumannii KACC 12454 (AB^KACC ), wild-type A. baumannii CCARM 12088 (AB^CCARM ), PMB-adapted AB^KACC , PMB-adapted AB^CCARM , stabilized AB^KACC and stabilized AB^CCARM were used in this study. Compared to the wild-type AB^KACC , the MICs of PMB were increased from 2 to 128 μg ml^-1 against PMB-adapted AB^KACC , while MICs of CIP, MER, TET and TOB were decreased from 2 to 1 μg ml^-1 , 16 to 1 μg ml^-1 , 16 to 2 μg ml^-1 and 64 to 16 μg ml^-1 , respectively. The PMB-adapted AB^CCARM was resistant to CIP (32 μg ml^-1 ) and PMB (64 μg ml^-1 ) compared to the wild-type AB^CCARM . The resistance of stabilized AB^KACC and AB^CCARM to all antibiotics was lost after antibiotic-free culture in the exception of CIP and TET. The susceptibilities of wild-type, PMB-adapted and stabilized AB^KACC and AB^CCARM to CIP, MER, PMB, TET and TOB were increased in the presence of β-lactamase and efflux pump inhibitors. The high levels of relative fitness were observed for stabilized AB^KACC , PMB-adapted AB^CCARM and stabilized AB^CCARM . The stabilized AB^KACC and PMB-adapted AB^CCARM were highly heteroresistance to PMB and TET, respectively. The PMB-adapted AB^KACC and AB^CCARM showed various antibiotic patterns, known as collateral susceptibility and collateral resistance. The results provide useful information for designing effective antibiotic regimens that can enhance the antibiotic activity against A. baumannii infections.

Multifunctional Additives for High-Energy-Density Lithium-Ion Batteries: Improved Conductive Additive/Binder Networks and Enhanced Electrochemical Properties

Cylindrical-type cells have been widely adopted by major battery and electric vehicle manufacturers owing to their price competitiveness, safety, and easy expandability. However, placement of electrodes at the core of cylindrical cells is currently restricted because of high electrode curvature and the lack of specialized electrodes and electrode materials. Here, we report the realization of highly flexible high-energy-density electrodes (active material loading of >98.4%) that can be used at the cores of cylindrical cells. The improved properties result from the introduction of a multifunctional poly(melamine-co-formaldehyde) (MF copolymer) additive, which yields a relatively more fluidic and well-dispersed slurry using only 0.08 wt %. MF copolymer-mediated formation of completely wrapped CNT/PVDF networks on LiCoO₂ (LCO) and accompanying contact enhancement between LCO and carbon nanotubes (CNTs) resulted in an increase of electrical and mechanical properties of the two types (composites with or without collectors) of electrodes compared with those of additive-free electrodes. Flexibility tests were carried out by rolling electrodes onto cylinder substrates (diameters of ca. 1 and 10 mm); this process resulted in relatively lower resistance changes of the MF copolymer-containing electrodes than for the reference electrodes. In addition, capacity retention after 100 cycles for cells with and without MF copolymers was approximately 10-20% better for the samples with the MF copolymer than for those without. CNT/PVDF networks with MF copolymers were proven to induce a relatively thin and stable cathode electrolyte interface layer accompanying the chemical bond formation during cycling.

Medical Care Disruptions During the First Six-Months of the COVID19 Pandemic: The Experience of Older Breast Cancer Survivors

Purpose.

Older cancer survivors required medical care during the COVID-19 pandemic despite infection risks, but there are limited data on medical care in this age group.

Methods.

We evaluated care disruptions in a longitudinal cohort of non-metastatic breast cancer survivors ages 60–98 from five US regions (n=321). Survivors completed a web-based or telephone survey from May 27, 2020 to September 11, 2020. Care disruptions included self-reported interruptions in ability to see doctors, receive treatment or supportive therapies, or fill prescriptions. Logistic regression models evaluated bivariate and multivariate associations between care disruptions and education, medical, psychosocial and COVID-19-related factors. Multivariate models included age, county COVID-19 rates, comorbidity and post-diagnosis time.

Results.

There was a high response rate (n=262, 81.6%). Survivors were 32.2 months post-diagnosis (SD 17.5, range 4–73). Nearly half (48%) reported a medical disruption. The unadjusted odds of care disruptions were significantly higher with more education (OR 1.23 per one-year increase, 95% CI 1.09–1.39, p =0.001) and greater depression (OR 1.04 per one-point increase in CES-D score, CI 1.003–1.08, p=0.033); tangible support decreased the odds of disruptions (OR 0.99, 95% CI 0.97–0.99 per one-point increase, p=0.012). There was a trend for associations between disruptions and comorbidity (unadjusted OR 1.13 per 1 added comorbidity, 95% CI 0.99–1.29, p=0.07). Adjusting for covariates, only higher education (p=0.001) and tangible social support (p=0.006) remained significantly associated with having care disruptions.

Conclusions.

Older breast cancer survivors reported high rates of medical care disruptions during the COVID-19 pandemic and psychosocial factors were associated with care disruptions.

Early Outcomes After Surgical Management of Geriatric Patella Fractures

Objectives:

To report the incidence and risk factors for prolonged hospitalization, discharge to a facility, and postoperative complications in geriatric patients who underwent surgery for patella fracture.

Design:

Retrospective database review.

Setting:

The American College of Surgeons—National Surgical Quality Improvement Program (NSQIP) collects data from 600 hospitals across the United States.

Patients/Participants:

NSQIP patients over 65 years of age with patella fractures.

Intervention:

Surgical fixation of patella fracture including extensor mechanism repair.

Main Outcome Measurements:

Prolonged hospitalization, discharge to a facility, and 30-day post-operative complications.

Results:

1721 patients were included in the study. The average age was 74.9 years. 358 (20.8%) patients were male. 122 (7.1%) patients had a length of stay greater than 7 days. Factors associated with prolonged length of stay include pre-existing renal failure, need for emergent surgery, and time to surgery greater than 24 hours from admission. 640 patients (37.2%) of patients were discharged to a facility after surgery. Discharge to facility was associated with age >77 years, obesity, anemia, thrombocytopenia, pre-operative SIRS, and CCI > 0.5. Admission from home decreased the odds of discharge to a facility. The most common postoperative complications in this population were unplanned readmission (3.4%), unplanned reoperation (2.7%), surgical site infection (1.1%), mortality (1.0%), venous thromboembolism (0.8%), and wound dehiscence (0.2%). Complication rates increased with anemia and ASA class IV-V.

Conclusions:

Geriatric patients undergoing operative intervention for patella fractures are at high risk for prolonged hospitalization, discharge to facility, unplanned readmission or reoperation, and surgical site complications in the first 30 days following surgery. This study highlights modifiable and non-modifiable risk factors associated with adverse events. Early recognition of these factors can allow for close monitoring and multidisciplinary intervention in the perioperative period to improve outcomes.

Level of Evidence:

Prognostic level III.

Impact of a specialised palliative care intervention in patients with advanced soft tissue sarcoma - a single-centre retrospective analysis

BACKGROUND

Soft tissue sarcomas (STS) account for less than 1% of all malignancies. Approximately 50% of the patients develop metastases with limited survival in the course of their disease. For those patients, palliative treatment aiming at symptom relief and improvement of quality of life is most important. However, data on symptom burden and palliative intervention are limited in STS patients.

AIM

Our study evaluates the effectiveness of a palliative care intervention on symptom relief and quality of life in STS patients.

DESIGN/SETTING

We retrospectively analysed 53 inpatient visits of 34 patients with advanced STS, admitted to our palliative care unit between 2012 and 2018. Symptom burden was measured with a standardised base assessment questionnaire at admission and discharge.

RESULTS

Median disease duration before admission was 24 months, 85% of patients had metastases. The predominant indication for admission was pain, weakness and fatigue. Palliative care intervention led to a significant reduction of pain: median NRS for acute pain was reduced from 3 to 1 (p < 0.001), pain within the last 24 h from 5 to 2 (p < 0.001) and of the median MIDOS symptom score: 18 to 13 (p < 0.001). Also, the median stress level, according to the distress thermometer, was reduced significantly: 7.5 to 5 (p = 0.027).

CONCLUSIONS

Our data underline that specialised palliative care intervention leads to significant symptom relief in patients with advanced STS. Further efforts should aim for an early integration of palliative care in these patients focusing primarily on the identification of subjects at high risk for severe symptomatic disease.

The Infected Diabetic Foot: Re-evaluating the Infectious Diseases Society of America Diabetic Foot Infection Classification

BACKGROUND

We provide evidence to revise the Infectious Diseases Society of America (IDSA) diabetic foot infection classification by adding a separate tier for osteomyelitis and evaluating if moderate and severe infection criteria improve the classification's ability to direct therapy and determine outcomes.

METHODS

We retrospectively evaluated 294 patients with moderate and severe infections. Osteomyelitis was confirmed by bone culture or histopathology. Soft tissue infection (STI) was based on negative bone culture, magnetic resonance imaging, or single-photon emission computed tomography. We stratified STI and osteomyelitis using IDSA criteria for moderate and severe infections and compared outcomes and complications.

RESULTS

Osteomyelitis patients had greater antibiotic duration (32.5 ± 46.8 vs 63.8 ± 55.1 days; P < .01), surgery frequency (55.5% vs 99.4%; P < .01), number of surgeries (2.1 ± 1.3 vs 3.3 ± 2.3; P < .01), amputations (26.3% vs 83.4%; P < .01), reinfection (38.0% vs 56.7%; P < .01), and length of stay (14.5 ± 14.9 vs 22.6 ± 19.0 days; P < .01). There were no differences in moderate and severe STI outcomes except for infection readmissions (46.2% vs 25.0%; P = .02), and acute kidney injury (31.2% vs 50.0%; P = .03). There were no differences in moderate and severe osteomyelitis except the number of surgeries (2.8 ± 2.1 vs 4.1 ± 2.5; P < .01) and length of stay (18.6 ± 17.5 vs 28.2 ± 17.7; P < .01).

CONCLUSIONS

The IDSA classification better reflects outcomes if risk categories are stratified by STI or osteomyelitis and moderate and severe infections are not categorized separately.

Using Artificial Intelligence Methods for Dental Image Analysis: State-of-the-Art Reviews

A large number of studies that use artificial intelligence (AI) methodologies to analyze medical imaging and support computer-aided diagnosis have been conducted in the biomedical engineering domain. Owing to the advances in dental diagnostic X-ray systems such as panoramic radiographs, periapical radiographs, and dental computed tomography (CT), especially, dual-energy cone beam CT (CBCT), dental image analysis now presents more opportunities to discover new results and findings. Recent researches on dental image analysis have been increasingly incorporating analytics that utilize AI methodologies that can be divided into conventional machine learning and deep learning approaches. This review first covers the theory on dual-energy CBCT and its applications in dentistry. Then, analytical methods for dental image analysis using conventional machine learning and deep learning methods are described. We conclude by discussing the issues and suggesting directions for research in future.

The infected diabetic foot: Can serum biomarkers predict osteomyelitis after hospital discharge for diabetic foot infections?

The aim of this study is to evaluate serum biomarkers to monitor high-risk patients for reinfection of bone. Thirty-five patients were prospectively enrolled with moderate to severe diabetic foot infections with suspicion of osteomyelitis. Bone samples were obtained for culture and histology. Clinical characteristics and outcomes of patients were compared using χ² square test. Biomarkers (white blood cell count, erythrocyte sedimentation rate, c-reactive protein, procalcitonin, interleukin-6, interleukin-8, and monocyte chemoattractant protein 1) were assessed at baseline, 3, and 6 weeks after treatment initiation and evaluated for correlation with reinfection of bone. After 6 weeks of antibiotic treatment, ESR at 73.5 mm/h (sensitivity 62.5%, specificity 100%, area under the receiver operating characteristic (AUROC) 0.7839, 95% CI 0.54-1.00, P < .01) and IL-8 at 15.09 mg/dL (sensitivity 42.9%, specificity 92.0% AUROC 0.6286, 95% CI 0.36-0.90, P = .0496) were associated with reinfection of bone. An increase in IL-8 from week 0 to 6 >0.95 mg/dL was associated with reinfection (sensitivity 71%, specificity 72% AUROC 0.7057, 95% CI 0.49-0.92, P = .04). An ESR change from week 0-6 of -16.5% (sensitivity 71.4%, specificity 86.4% AUROC 0.7403, 95% CI 0.48-1.00, P = .02), CRP (-)74.4% (sensitivity 66.7%, specificity 91.3% AUROC 0.7174, 95% CI 0.40-1.00, P = .04), IL-6 (-)49.9% (sensitivity 71.4%, specificity 76% AUROC 0.7371, 95% CI 0.47-1.00, P = .04), and IL-8 29% (sensitivity 85.7%, specificity 56.0% AUROC of 0.7343, 95% CI 0.54-0.93, P = .048) were associated with increased risk of reinfection. Pilot data suggest that serum biomarkers (ESR, IL8 and IL6, MCP-1) may be correlated with developing osteomyelitis and could be used to monitor high-risk patients for reinfection.

The brief window of time comprising a wheelchair transfer confers a significant fracture risk on elderly Americans

OBJECTIVES

Wheelchairs grant increased mobility to their users but can result in injuries of varying severities, including fractures which are often associated with wheelchair transfers. However, this fracture burden remains poorly characterized in elderly Americans. The purpose of this study was to report demographic and environmental risk factors for these injuries.

STUDY DESIGN

We used data from the National Electronic Injury Surveillance System (NEISS) for the years 2007-2017 to perform a retrospective, cross-sectional analysis of wheelchair transfer fractures in patients aged 65 years and older.

METHODS

Each yearly sample in the NEISS database was queried between 2007 and 2017 for fractures associated with wheelchair transfers in patients aged 65 years or older. The narrative sections of the database were individually read and reviewed to identify cases in which a patient explicitly transferred into or out of a wheelchair while sustaining said fracture.

RESULTS

Between 2007 and 2017, the average number of patients aged 65 years and older presenting to US emergency departments was 3924 (95% confidence interval [CI] = 2792-5055). A significantly higher percentage of fractures (61.8%; 95% CI = 56.7%-66.8%) is associated with transferring out of wheelchairs. Moreover, such fractures were often associated with transferring to and from beds (29.9%; 95% CI = 25.4%-34.3%), with the hip (37.5%; 95% CI = 33.3%-41.6%) being the most commonly fractured anatomical region overall. A majority of patients required admission to the hospital (60.2%; 95%CI = 52.4%-68.0%) and most wheelchair transfer fractures occurred at home (44.1%; 95% CI = 36.7%-51.5%), with women (71.9%; 95% CI = 68.3%-75.6%) comprising the majority of these patients.

CONCLUSIONS

Our findings show that wheelchair transfers are associated with significant risk of severe fracture in elderly Americans. As such, wheelchair transfer events merit extra attention from healthcare providers because they comprise a brief window of time relative to the number of occupancy hours in full-time wheelchair users yet can result in significant morbidity and mortality. Preventative measures and patient education should be encouraged to preserve patient mobility and reduce injury.

Thirty-Day Outcomes following Pediatric Bone and Soft Tissue Sarcoma Surgery: A NSQIP Pediatrics Analysis

BACKGROUND

Pediatric bone and soft tissue sarcomas are rare; therefore, national registries are essential tools for orthopedic oncology research. Past studies provide excellent data on long-term prognosis and survival trends but fail to examine treatment-specific morbidity. The aim of this study is to use a national registry to describe patient demographics, comorbidities, and adverse events in the first thirty days following surgical management of pediatric bone and soft tissue sarcomas.

METHODS

A retrospective review of patients in the American College of Surgeons National Surgical Quality Improvement Program-Pediatrics database (NSQIP-P) was performed. The cohort was partitioned by tumor origin (bone versus soft tissue) and tumor location (axial versus appendicular).

RESULTS

One-hundred ninety-two patients were identified. Bone sarcomas were more common (71.9%) and predominately appendicular (62.3%), while soft tissue sarcomas were predominately axial (77.8%). The overall complication rate was 8.9%. The most frequent etiologies were wound dehiscence (3.6%) and infectious complications such as surgical site infections (2.6%), pneumonia (1.6%), urinary tract infections (1.6%), and C. diff colitis (1.0%). Twenty-four percent of patients experienced bleeding requiring transfusion. The unplanned readmission rate was 12.5% (3.6% related to principle procedure), and the unplanned reoperation rate was 4.7% (4.2% related to principle procedure). The mortality rate was 1.0%. Neoadjuvant chemotherapy was associated with higher rates of wound dehiscence and infectious complications. There were no differences in adverse events with respect to tumor origin or location.

CONCLUSION

Approximately 1 in 11 pediatric patients will experience a complication in the first thirty days following surgery. However, perioperative mortality remains low. This study represents the first comprehensive review of pediatric bone and soft tissue sarcoma surgery in the NSQIP-P database. As the case volume of NSQIP-P continues to grow, NSQIP-P has the potential to become a powerful tool for pediatric orthopedic oncology research.

Acetabular Protrusio in Patients With Osteogenesis Imperfecta: Risk Factors and Progression

BACKGROUND

Osteogenesis imperfecta (OI) is a genetic disorder commonly associated with osteopenia, osteoporosis, bone fractures, bone deformities, and other clinical features. A frequent radiologic finding with OI is acetabular protrusio (AP). We hypothesized that AP develops in patients with OI over time. In addition, we hypothesized that AP also develops in patients with OI without radiographic evidence of AP on initial examination.

METHODS

Medical records and radiographs of 55 patients (109 hips) diagnosed with OI evaluated at our institution were retrospectively reviewed. Previously established radiographic criteria using the center-edge (CE) angle of Wiberg, position of the acetabulum relative to the iliopectineal line, crossing of the acetabulum across the ilioischial (Kohler) line, and position of the teardrop figure relative to the ilioischial (Kohler) line were utilized to assess AP severity. In addition, pharmacological treatments and patient factors including body mass index (BMI) were recorded. Radiographs of patients with OI that were taken ≥2 years apart were analyzed utilizing AP radiographic criteria to assess for changes. The changes in AP-related measurements were standardized by distance or degree per year. In addition, patient factors were evaluated for associations with AP development.

RESULTS

In this series of 109 hips (55 patients), incidence of AP in earliest radiographs was 45% (49/109). Patients with OI type I and III demonstrated the highest incidence of AP (65%). Among the hips that did not meet the criteria for AP in their early radiographs, 24 (40%) were positive for AP by their latest radiograph. In the hips that initially presented with AP, 42% showed increased CE angles on later radiographs. Twenty-six hips (24%) showed either no observable changes or reduced CE angles. Risk factors that were significantly associated with greater odds of developing AP included (1) an age under 12; (2) a BMI>25; (3) presence of AP of the contralateral hip; and (4) female sex. Bisphosphonates, vitamin D, physical therapy, and other drugs related to treatment of OI reduced the risk of developing AP but did not achieve statistical significance.

CONCLUSIONS

AP is a common finding in OI patients (54%). Among hips of OI patients that met criteria for AP in early radiographs, 42% (20/48) demonstrated greater CE angles in their latest radiographs. Similar changes were observed in OI patients who did not initially meet criteria for diagnosis for AP. However, CE angle measurements between the 2 groups did not significantly differ (P=0.71). In terms of Kohler line crossing, patients that met criteria for AP in early radiographs had significantly greater change per year than those that did not have AP criteria (P<0.05). The findings suggest AP may develop over time in patients with OI and may be influenced by patient factors such as age, sex, and BMI. In addition, unilateral AP may have a significant impact on the development of AP of the contralateral hip.

LEVEL OF EVIDENCE

Level IV-retrospective case series.

P966 Impact of systolic dysfunction and elevated left ventricular end diastolic pressure on three years clinical outcome in patients with atrial fibrillation

Background

Systolic and diastolic dysfunction is related with adverse clinical outcomes in the patients with sinus rhythm. Purpose: The aim of this study is to clarify the prognostic significance of both systolic and diastolic dysfunction in the patients with chronic persistent atrial fibrillation (AF). Methods: A total of 114 consecutive patients who have chronic persistent AF. Whole patients were divided into 2 groups according to left ventricular ejection fraction (LVEF): those with an LVEF &lt; 50 (n = 24) (REF) and those with an LVEF ≥ 50 (n = 90) (PEF). And PEF group was also divided into two groups according to left ventricular end diastolic filling pressure (LVEDP): patients with LVEDP ≥ 15 mmHg (n = 38) and those with &lt; 15 mmHg (n = 52). Results: 3-year clinical outcomes were compared between each groups (PEF groups vs. REF groups and LVEDP ≥ 15 mmHg vs LVEDP &lt; 15 mmHg). The incidence of death, hospitalization, stroke, bleeding, AF with rapid ventricular rhythm (RVR) and heart failure (HF) hospitalization were similar PEF and REF group. However, during 3-year follow up period, the incidence of HF hospitalization (29.2% vs 8.9%, p &lt; 0.02) and AF with RVR (20.8% vs 3.3%, p &lt; 0.01) were frequent in REF group compared with PEF group. In multivariate analysis, REF is an only predictor of HF hospitalization (Table 1). Conclusion: During 3-year follow up period, systolic dysfunction is an important predictor of HF hospitalization in AF patients. However, elevated LVEDP is not related with 3-year adverse clinical outcomes in AF patients without systolic dysfunction.

Table 1 variable Odd Ratio (HR) 95% Confidence Interval (CI) P Age .973 .925-1.023 .286 Diabetes mellitus .487 .138-1.721 .264 BNP 1.000 1.000-1.000 .908 Hypertension 1.061 .330-3.413 .921 LVEDP &gt; 15 mmHg 1.302 .396-4.285 .664 EF &lt; 50 4.712 1.478-15.016 .009 Predictors of 3-year follow-up clinical outcomes of all participants

Renal Function as a Predictor of Early Transmetatarsal Amputation Failure

Chronic kidney disease (CKD) is a major concern in patients with foot disease because it is associated with high rates of neuropathy, peripheral vascular disease, and poor wound healing. The purpose of this study was to evaluate renal dysfunction as a risk factor for reamputation after initial transmetatarsal amputation (TMA). Patients who underwent a TMA were retrospectively identified in the American College of Surgeons National Surgical Quality Improvement Program database. Of 2018 patients, reamputation after TMA occurred in 4.4%. End-stage renal disease (ESRD) was associated with 100% increased odds of TMA failure (adjusted odds ratio [OR] = 2.00; 95% CI = 1.10, 3.52), 128% increased odds of major amputation (adjusted OR = 2.28; 95% CI = 1.27, 3.96), and 182% increased odds of 30-day mortality (adjusted OR = 2.82; 95% CI = 1.69, 4.64). In addition, white blood cell count >10 000/mm³ and deep infection at the time of surgery were independently associated with TMA failure. In conclusion, severe renal dysfunction is associated with TMA failure in the short-term, perioperative period. There was no incremental increase in risk of TMA failure with worsening level of renal function before ESRD. A multidisciplinary approach should be implemented in patients with CKD to prevent foot-related pathologies that may necessitate lower-extremity amputation. Levels of Evidence: Level III: Retrospective cohort study.

3334Updated meta-analysis of biodegradable polymer drug-eluting stent versus second-generation durable polymer drug-eluting stent implantations

Background

Data regarding clinical outcomes of biodegradable polymer drug-eluting stent (BP-DES) versus second-generation durable polymer drug-eluting stent (DP-DES) in patients undergoing percutaneous coronary intervention (PCI) are inconclusive.

Purpose

We aimed to perform a meta-analysis to investigate the clinical outcomes of BP-DES compared with second-generation DP-DES in patients who have undergone PCI.

Methods

We searched PubMed, MEDLINE, EMBASE, and Cochrane databases through January 2019 for randomized controlled trials comparing BP-DES with second-generation DP-DES in patients treated with PCI. All-cause death, cardiac death, myocardial infarction (MI), target vessel revascularization (TVR), target lesion revascularization (TLR), definite/probable stent thrombosis (ST) were compared between the groups. Additionally, a landmark analysis with the landmark set at 1 year and a subgroup analysis according to stent characteristics were performed.

Results

Data from 23 trials including 28802 randomized patients were analyzed. At a median follow up of 3.1 years, no significant differences were found in terms of all-cause death (odds ratio [OR] 1.05, 95% confidence interval [CI] 0.95–1.16), cardiac death (OR 1.01, 95% CI 0.87–1.17), MI (OR 0.92, 95% CI 0.82–1.03), TVR (OR 0.97, 95% CI 0.86–1.11), TLR (OR 0.97, 95% CI 0.85–1.11), and definite/probable ST (OR 0.86, 95% CI 0.70–1.07) between the groups. Landmark analysis showed that there were similar risks in all-cause death (OR 1.04, 95% CI 0.93–1.17), cardiac death (OR 1.11, 95% CI 0.92–1.36), MI (OR 0.94, 95% CI 0.79–1.13), TVR (OR 0.95, 95% CI 0.73–1.23), TLR (OR 1.00, 95% CI 0.80–1.24), and definite/probable ST (OR 0.92, 95% CI 0.67–1.28) between the groups. The similar tendency of any study endpoints between the groups was consistent in the subgroup, including stent platform (stainless steel vs. alloy), the drug coating distribution (abluminal vs. circumferential), the polymer degradation period (<6 months vs. >6 months), or the drug release duration (<6 months vs. >6 months) of BP-DES, or the DAPT duration (≥6 months vs. ≥12 months). However, the uses of BP-DES with sirolimus-eluting (OR 0.84, 95% CI 0.72–0.98) or ultrathin strut (defined as <70μm; OR 0.81, 95% CI 0.68–0.97) were predictive for lower risk of MI.

Clinical outcomes

Conclusions

In our updated meta-analysis, BP-DES implantation was associated with comparable clinical outcomes compared with second-generation DP-DES implantation. However, PCI with ultrathin biodegradable polymer sirolimus-eluting stent could reduce the risk of MI.