Defining Posterior Wall Fragments in Associated Both Column Acetabular Fractures (OTA/AO 62C).

OBJECTIVE: Associated both column acetabular fractures (OTA/AO 62C) with concomitant posterior wall fracture fragments (ABC + PW) have not been well-defined. The purpose of this study was to report on the incidence and morphology of ABC + PW fractures. METHODS: A retrospective review of associated both column (ABC) fractures between 2014 and 2020 was performed. Computed tomography scans including 3-D surface rendered reformats for each were reviewed to determine whether a posterior wall (PW) fragment was present and its morphologic characteristics. RESULTS: One hundred fifty-two ABC fractures were identified. Sixty-two fractures (41%) were identified as ABC + PW. 3D-computed tomographies were available on 58 fractures. Morphologic analysis was performed based on the relationship of the fracture to the gluteal pillar. Twenty PW fragments were posterior to the gluteal pillar, 19 extended into the gluteal pillar, and 19 extended anterior. Fifty-two fractures were treated with operative fixation; 32 (62%) were clamped and fixed with screws from the same anterior approach whereas 15 (29%) required a separate posterior approach; and no fixation was placed in 5 (9%). 29 of 32 PW fragments (91%) requiring fixation that extended into or anterior to the pillar were fixed from the anterior approach, and 7 of 15 posterior fractures (47%) required a separate posterior approach. CONCLUSIONS: A separate PW fragment was identified in 41% of ABC fractures. Their variation in morphology can be classified into 3 types based on the relation to the gluteal pillar that has potential implications for treatment from the anterior approach compared with requiring a separate posterior approach. We suggest these data could be used to update the 2018 OTA/AO Fracture Compendium. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Prevalence of Vitamin D Deficiency in Patients With Charcot Arthropathy: A Single-Center Analysis.

INTRODUCTION: Vitamin D deficiency may be a potentially modifiable risk factor in patients with orthopaedic conditions including Charcot arthropathy. The purpose of this study was to determine the prevalence of vitamin D deficiency and insufficiency in patients with Charcot arthropathy. METHODS: All patients with Charcot arthropathy seen in our foot and ankle surgery clinic from January 2017 through June 2021 were screened for serum 25-hydroxyvitamin D levels. Patients were categorized as sufficient, insufficient, or deficient based on previously accepted guidelines. The prevalence of vitamin D deficiency and insufficiency was calculated. RESULTS: A total of 57 subjects were included in this study after meeting the inclusion criteria. Of these, 27 (47.4%) were found to be deficient in vitamin D, 21 (36.8%) were insufficient in vitamin D, and 9 (15.8%) were sufficient in vitamin D. Overall, 84.2% of the cohort was found to be either insufficient or deficient in vitamin D. CONCLUSION: Vitamin D insufficiency and deficiency is highly prevalent in patients with Charcot arthropathy. As such, it is possible that this may play a role in the pathogenesis of Charcot arthropathy and may represent a potentially modifiable risk factor that could be optimized during the management of patients with Charcot arthropathy.

Correlating Arthroscopic and Radiographic Findings of Deep Deltoid Ligament Injuries in Rotational Ankle Fractures.

BACKGROUND: The deep deltoid ligament (DDL) is a key stabilizer to the medial ankle and ankle mortise and can be disrupted in ligamentous supination external rotation type IV (LSER4) ankle fractures. The purpose of this study was to define the medial clear space (MCS) measurement on injury mortise radiographs that corresponds with complete DDL injury. METHODS: A retrospective record review at a level 1 hospital was performed identifying patients with LSER4 ankle fractures who underwent arthroscopy and open reduction internal fixation. Chart reviews provided arthroscopic images and operative reports. Complete DDL injury was defined as arthroscopic visualization of the posterior tibial tendon (PTT). Inability to completely visualize the PTT was defined as a partial DDL injury. MCS was measured on injury mortise radiographs. Eighteen subjects met inclusion criteria. RESULTS: Twelve subjects had complete and 6 subjects had partial DDL injury based on arthroscopic findings. Patients with complete DDL injury and those with partial DDL injury had injury radiograph MCS ranging from 5.5 to 29.9 mm and 4.0 to 5.0 mm, respectively. All patients with MCS ≥5.5 mm on injury radiographs had complete DDL injury and all patients with MCS ≤5.0 mm on injury radiographs had partial DDL injury. CONCLUSION: Complete DDL injury was found on injury ankle mortise radiographs as MCS widening of ≥5.5 mm, which correlated with arthroscopic visualization of the PTT. Using this cutoff, surgeons can surmise the presence of a complete deltoid ligament injury, allowing for improved preoperative planning. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Demographics and Epidemiology of Discoid Menisci of the Knee: Analysis of a Large Regional Insurance Database.

BACKGROUND: A discoid meniscus is a morphological variant of normal knee joint meniscus shape and ultrastructure that can lead to traumatic tearing of this tissue and early joint osteoarthritis. PURPOSE/HYPOTHESIS: The purpose of this study was to determine the prevalence of discoid menisci in a large, ethnically diverse regional cohort and to evaluate possible risk factors. The hypothesis was that there would be no difference in the epidemiological distribution of discoid menisci based on ethnicity or sex. STUDY DESIGN: Descriptive epidemiology study. METHODS: The study population was from a regional, integrated health care system cohort from Kaiser Permanente of Southern California that, as of 2016, included more than 4.5 million patients. Patient demographics included age, sex, and ethnicity within this cohort. Potential risk factors analyzed included age, sex, ethnicity, and body mass index (BMI). Unique characteristics of a discoid meniscus were analyzed, including a symptomatic versus asymptomatic meniscus, location of meniscal tear and type of meniscus, and frequency of meniscal surgical treatment. RESULTS: A total of 223 patients with a confirmed discoid meniscus were identified, yielding an overall prevalence rate of 4.88 per 100,000 patients. Those identifying as Black had the lowest prevalence (2.68/100,000), while Hispanic ethnicity had the highest (6.01/100,000). However, there was no significant difference with regard to ethnicity (P = .283), nor any significant difference between sexes. BMI did not significantly influence the rate of discoid menisci (P = .504). A majority (77.5%) of patients were symptomatic, while 22.5% of patients with discoid menisci were asymptomatic and discovered incidentally. Symptomatic discoid menisci were more likely to be operated on compared with asymptomatic discoid menisci (71% vs 14%, respectively; P = .001; odds ratio, 14.8 [95% CI, 5.8-37.2]). Horizontal and bucket-handle tears were the more common tear types. Of the discoid menisci in this cohort, 55.6% underwent surgery, with 95.2% undergoing reported saucerization. CONCLUSION: In this very diverse population-based cohort of patients, there did not seem to be a significant predilection of discoid menisci with regard to ethnicity. Neither sex nor BMI significantly influenced the rate of discoid menisci. More than three-quarters of those with a diagnosed discoid meniscus were symptomatic. Of the tears that occurred with discoid menisci, horizontal and bucket-handle tears made up the largest proportion.

Current illicit drug use profile of orthopaedic trauma patients and its effect on hospital length of stay.

INTRODUCTION: The purpose of this study was to investigate the prevalence of illicit drug use among patients admitted with traumatic orthopaedic injuries and to determine its effect on hospital length of stay (LOS). We hypothesized that patients with pre-injury drug use would have a longer hospital LOS compared to those who do not use drugs. METHODS: We conducted a retrospective cohort study at our level 1 urban trauma center of patients admitted with traumatic orthopaedic injuries between 2013 and 2015 with urine toxicology screening. We collected demographic and hospital LOS data from chart review. RESULTS: Of 611 patients, over half (55%) had a positive drug screen: marijuana (41%), amphetamine (19%), cocaine (7%), and/or PCP (2%). The highest incidence of drug use was in males under 19 years of age (81%). Patients with any drug use had a longer hospital LOS compared to those who did not use drugs (8.3 vs. 6.3 days; p = 0.03). Patients who used amphetamines had a longer hospital LOS than those patients who did not (9.5 vs. 6.9 days; p = 0.01). CONCLUSION: Compared to the orthopaedic trauma population two decades ago, the current population using illicit drugs is younger (<30 years) with an increased preference for amphetamine and marijuana and a decreased preference for cocaine. Pre-injury drug use was associated with a longer hospital LOS in patients with a traumatic orthopaedic injury. Knowledge of the current trends in illicit drug use amongst orthopaedic trauma patients could facilitate medical decision-making regarding clinical care and optimizing resource utilization in this complex population of individuals.

Evaluation of the R2D2 protocol: A Novel Method for Assessing Emergency Department Disposition for Residents.

BACKGROUND: The emergency department (ED) disposition and discharge process is a critical period in a patient's transition from an acute care setting to self-care or a bridge to other healthcare providers. The emergency physician plays a pivotal role in this process and is ultimately responsible for ensuring that patients are safely released from their care. We developed a protocol to guide residents through the ED discharge process using the mnemonic "R2D2": reassess the patient, recheck the workup, discuss the disposition plan with the attending, and finally discuss the discharge plan with the patient. OBJECTIVES: The objective was to assess the effectiveness of the R2D2 discharge protocol, executed by resident physicians, in improving patients' understanding of their diagnosis and treatment plans. METHODS: This is a before-and-after study in the ED of a county hospital and included all patients discharged by a resident physician from the ED 1 week before and 1 week after implementation of the R2D2 protocol. All participating resident physicians received a brief 10-minute orientation to the R2D2 protocol at the end of the first week of the study period. Consecutive patients were identified, consented, and given a brief questionnaire about their discharge by research assistants. Certain exclusion criteria applied such as inability to speak English or Spanish or no phone for follow-up. One to 2 weeks after ED discharge, patients from both groups were contacted by phone to assess their recall of their discharge instructions. Data analyses were performed using Fisher's exact, chi-square tests, or two independent-sample proportions tests as appropriate. RESULTS: We recruited 164 patients in the control group and 148 patients in the intervention group, totaling 312 patients. A total of 73.8% of the control group patients and 77.0% of the intervention group patients completed the follow-up. On telephone follow-up, 88% of the intervention patients knew their discharge diagnosis versus only 74% of control patients (p = 0.0062). Eighty percent of intervention patients knew their discharge treatment plan versus only 67% of control patients (p = 0.0259). CONCLUSIONS: The R2D2 protocol resulted in significant improvement in patients' understanding of their discharge diagnosis and treatment plan.

Remodeling of the tight junction during recovery from exposure to hydrogen peroxide in kidney epithelial cells.

Renal ischemia-reperfusion injury results in oxidative stress-induced alterations in barrier function. Activation of the mitogen-activated protein (MAP) kinase pathway during recovery from oxidative stress may be an effector of oxidant-induced tight junction reorganization. We hypothesized that tight junction composition and barrier function would be perturbed during recovery from oxidative stress. We developed a model of short-term H(2)O(2) exposure followed by recovery using Madin Darby canine kidney (MDCK II) cells. H(2)O(2) perturbs barrier function without a significant cytotoxic effect except in significant doses. ERK-1/2 and p38, both enzymes of the MAP kinase pathway, were activated within minutes of exposure to H(2)O(2). Transient exposure to H(2)O(2) produced a biphasic response in the transepithelial electrical resistance (TER). An initial drop in TER at 6 h was followed by a significant increase at 24 h. Inhibition of ERK-1/2 activation attenuated the increase in TER observed at 24 h. Expression of occludin initially decreased, followed by partial recovery at 24 h. In contrast, claudin-1 levels decreased and failed to recover at 24 h. Claudin-2 levels were markedly decreased at 24 h; however, inhibition of ERK-1/2 activation was protective. Occludin and claudin-1 localization at the apical membrane on immunofluorescence images was fragmented at 6 h after H(2)O(2) exposure with subsequent recovery of appropriate localization by 24 h. MDCK II cell recovery after H(2)O(2) exposure is associated with functional and structural modifications of the tight junction that are mediated in part by activation of the MAP kinase enzymes ERK-1/2 and p38.