More Than a Flesh Wound: Trisomy 21 Patients Undergoing Posterior Spinal Fusion for Scoliosis Have High Odds of Wound Complications.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Patients with trisomy 21 (T21) often have soft tissue differences that lead to greater risk of postoperative wound complications. Our aim was to use a matched cohort of adolescent idiopathic scoliosis (AIS) patients with >2 year outcomes to determine odds of specific wound complications when comparing T21 and AIS patients. METHODS: 14 T21 and 544 AIS patients were available for matching. Propensity score matching was conducted using logistic regression models and yielded a 1:5 match of 14 T21 patients and 70 AIS patients. Bivariate analyses were conducted across both patient groups. The proportion of wound complications was estimated along with a 95% confidence interval. Multivariable logistic regression analysis was utilized to determine if there was a significant association between T21 patients and wound outcomes. RESULTS: 64% of T21 patients experienced a wound complication (9/14; 95% CI = 35.63-86.02) while only 3% of the AIS patients experienced a wound complication (2/70; 95% CI = .50-10.86). Patients with T21 had 56.6 times the odds of having a wound complication compared to matched AIS patients (OR = 56.57; 95% CI = 8.12-394.35; P < .001), controlling for age at surgery, BMI percentile, and propensity score. T21 patients had 10.4 times the odds of reoperation compared to AIS patients (OR = 10.36; 95% CI = 1.62-66.02; P = .01). CONCLUSION: T21 patients have 10.4× the odds of reoperation and 56.6× the odds of overall wound complication when compared to AIS patients in a 1:5 matched cohort with appropriate controls. This is important for surgical planning, surgeon awareness, and communication with families preoperatively.

Patient understanding regarding opioid use in an orthopaedic trauma surgery population: a survey study.

BACKGROUND: Prior studies have assessed provider knowledge and factors associated with opioid misuse; similar studies evaluating patient knowledge are lacking. The purpose of this study was to assess the degree of understanding regarding opioid use in orthopaedic trauma patients. We also sought to determine the demographic factors and clinical and personal experiences associated with level of understanding. METHODS: One hundred and sixty-six adult orthopaedic trauma surgery patients across two clinical sites of an academic institution participated in an internet-based survey (2352 invited, 7.1% response rate). Demographic, clinical, and personal experience variables, as well as perceptions surrounding opioid use were collected. Relationships between patient characteristics and opioid perceptions were identified using univariate and multivariable logistic regressions. Alpha = 0.05. RESULTS: Excellent recognition (> 85% correct) of common opioids, side effects, withdrawal symptoms, and disposal methods was demonstrated by 29%, 10%, 30%, and 2.4% of patients; poor recognition (< 55%) by 11%, 56%, 33%, and 52% of patients, respectively. Compared with white patients, non-white patients had 7.8 times greater odds (95% confidence interval [CI] 1.9-31) of perceiving addiction discrepancy (p = 0.004). Employed patients with higher education levels were less likely to have excellent understanding of side effects (adjusted odds ratio [aOR] 0.06, 95% CI 0.006-0.56; p = 0.01) and to understand that dependence can occur within 2 weeks (aOR 0.28, 95% CI 0.09-0.86; p = 0.03) than unemployed patients. Patients in the second least disadvantaged ADI quartile were more knowledgeable about side effects (aOR 8.8, 95% CI 1.7-46) and withdrawal symptoms (aOR 2.7, 95% CI 1.0-7.2; p = 0.046) than those in the least disadvantaged quartile. Patients who knew someone who was dependent or overdosed on opioids were less likely to perceive addiction discrepancy (aOR 0.24, 95% CI 0.07-0.76; p = 0.02) as well as more likely to have excellent knowledge of withdrawal symptoms (aOR 2.6, 95% CI 1.1-6.5, p = 0.03) and to understand that dependence can develop within 2 weeks (aOR 3.8, 95% CI 1.5-9.8, p = 0.005). CONCLUSIONS: Level of understanding regarding opioid use is low among orthopaedic trauma surgery patients. Clinical and personal experiences with opioids, in addition to demographics, should be emphasized in the clinical history.

Restarting Orthopaedic Care in a Pandemic: Ethical Framework and Case Examples.

The question about how to resume typical orthopaedic care during a pandemic, such as coronavirus disease 2019, should be framed not only as a logistic or safety question but also as an ethical question. The current published guidelines from surgical societies do not explicitly address ethical dilemmas, such as why public health ethics requires a cessation of nonemergency surgery or how to fairly allocate limited resources for delayed surgical care. We propose ethical guidance for the resumption of care on the basis of public health ethics with a focus on clinical equipoise, triage tiers, and flexibility. We then provide orthopaedic surgery examples to guide physicians in the ethical resumption of care.

Should "Pain Clearance" Be Routine for Elective Surgery?

For elective surgery, preoperative planning for patients with comorbidities tends to address risk stratification, cardiac clearance, and anticoagulation. This commentary suggests that chronic opioid use should be normalized as a comorbidity requiring "pain clearance" prior to elective surgery. Doing so would likely enhance team communication, optimize patient care, decrease stigma, and facilitate care transitioning and long-term planning.

A Bioethical Perspective for Navigating Moral Dilemmas Amidst the COVID-19 Pandemic.

The Coronavirus disease 2019 pandemic has been an unprecedented challenge to healthcare systems and clinicians around the globe. As the virus has spread, critical questions arose about how to best deliver health care in emergency situations where material and personnel resources become scarce. Clinicians who excel at caring for the individual patient at the bedside are now being reoriented into a system where they are being asked to see the collective public as their responsibility. As such, the clinical ethics that clinicians are accustomed to practicing are being modified by a framework of public health ethics defined by the presence of a global pandemic. There are many unknowns about Coronavirus disease 2019, which makes it difficult to provide consistent recommendations and guidelines that uniformly apply to all situations. This lack of consensus leads to the clinicians' confusion and distress. Real-life dilemmas about how to allocate resources and provide care in hotspot cities make explicit the need for careful ethical analysis, but the need runs far deeper than that; even when not trading some lives against others, the responsibilities of both individual clinicians and the broader healthcare system are changing in the face of this crisis.

Salter-Harris type II fractures of the distal tibia: Residual postreduction displacement and outcomes-a STROBE compliant study.

We assessed factors associated with premature physeal closure (PPC) and outcomes after closed reduction of Salter-Harris type II (SH-II) fractures of the distal tibia. We reviewed patients with SH-II fractures of the distal tibia treated at our center from 2010 to 2015 with closed reduction and a non-weightbearing long-leg cast. Patients were categorized by immediate postreduction displacement: minimal, <2 mm; moderate, 2 to 4 mm; or severe, >4 mm. Demographic data, radiographic data, and Lower Extremity Functional Scale (LEFS) scores were recorded.Fifty-nine patients (27 girls, 31 right ankles, 26 concomitant fibula fractures) were included, with a mean (±SD) age at injury of 12.0 ±â€Š2.2 years. Mean maximum fracture displacements were 6.6 ±â€Š6.5 mm initially, 2.7 ±â€Š2.0 mm postreduction, and 0.4 ±â€Š0.7 mm at final follow-up. After reduction, displacement was minimal in 23 patients, moderate in 21, and severe in 15. Fourteen patients developed PPC, with no significant differences between postreduction displacement groups. Patients with high-grade injury mechanisms and/or initial displacement ≥4 mm had 12-fold and 14-fold greater odds, respectively, of PPC. Eighteen patients responded to the LEFS survey (mean 4.0 ±â€Š2.1 years after injury). LEFS scores did not differ significantly between postreduction displacement groups (P = .61).The PPC rate in this series of SH-II distal tibia fractures was 24% and did not differ by postreduction displacement. Initial fracture displacement and high-grade mechanisms of injury were associated with PPC. LEFS scores did not differ significantly by postreduction displacement.Level of Evidence: Level IV, case series.

The Times, They Are A-Changing: Women Entering Academic Orthopedics Today Are Choosing Nonpediatric Fellowships at a Growing Rate.

OBJECTIVE: Pediatrics and hand surgery have historically been the orthopaedic subspecialties with the highest female representations. We sought to identify the gender distribution of orthopedic surgical faculty by subspecialty, geography, and educational background. We hypothesized that the proportion of women entering pediatric orthopaedics has decreased since 1980. DESIGN: The Accreditation Council for Graduate Medical Education was used to generate a list of U.S. orthopedic residencies. Program websites were used to collect data regarding each faculty member's gender, residencies, fellowships, and graduation year. t tests were used to compare quantitative data and Fisher's exact tests to compare categorical data. Significance was defined as p < 0.05. SETTING: Publicly available data from official websites of U.S. orthopedic residencies. PARTICIPANTS: Of 153 residencies, 142 (93%) had accessible faculty lists. RESULTS: Of 3596 orthopedic surgeons, 7.9% were women. Among fellowship-trained faculty, 22% of pediatric orthopedists were women compared with 7.6% of faculty in other orthopedic subspecialties (p < 0.00001). There was a significantly higher percentage of female faculty in the West (13%) than in any other U.S. census region (p < 0.001 vs. Midwest, vs. South, and vs. Northeast). A strong correlation with time was found in number of women completing fellowships other than hand or pediatrics from 1980 to 2014 (R2 = 0.95); a strong inverse correlation with time was found for pediatrics as a percentage of fellowships completed by women during the same period (R2 = 0.94). CONCLUSIONS: Although pediatrics remains the most popular fellowship for female orthopedists, women who enter academic orthopedics are increasingly choosing nonpediatric subspecialties.

Fractures and Subsequent Graft Loss and Mortality among Older Kidney Transplant Recipients.

OBJECTIVES: Older adults who undergo kidney transplantation (KT) are living longer with a functioning graft and are at risk for age-related adverse events including fractures. Understanding recipient, transplant, and donor factors and the outcomes associated with fractures may help identify older KT recipients at increased risk. We determined incidence of hip, vertebral, and extremity fractures; assessed factors associated with incident fractures; and estimated associations between fractures and subsequent death-censored graft loss (DCGL) and mortality. DESIGN: This was a prospective cohort study of patients who underwent their first KT between January 1, 1999, and December 31, 2014. SETTING: We linked data from the Scientific Registry of Transplant Recipients to Medicare claims through the US Renal Data System. PARTICIPANTS: The analytic population included 47 815 KT recipients aged 55 years or older. MEASUREMENTS: We assessed the cumulative incidence of and factors associated with post-KT fractures (hip, vertebral, or extremity) using competing risks models. We estimated risk of DCGL and mortality after fracture using adjusted Cox proportional hazards models. RESULTS: The 5-year incidence of post-KT hip, vertebral, and extremity fracture for those aged 65 to 69 years was 2.2%, 1.0%, and 1.7%, respectively. Increasing age was associated with higher hip (adjusted hazard ratio [aHR] = 1.37 per 5-y increase; 95% confidence interval [CI] = 1.30-1.45) and vertebral (aHR = 1.31; 95% CI = 1.20-1.42) but not extremity (aHR = .97; 95% CI = .91-1.04) fracture risk. DCGL risk was higher after hip (aHR = 1.34; 95% CI = 1.12-1.60) and extremity (aHR = 1.30; 95% CI = 1.08-1.57) fracture. Mortality risk was higher after hip (aHR = 2.31; 95% CI = 2.11-2.52), vertebral (aHR = 2.80; 95% CI = 2.44-3.21), and extremity (aHR = 1.85; 95% CI = 1.64-2.10) fracture. CONCLUSION: Our findings suggest that older KT recipients are at higher risk for hip and vertebral fracture but not extremity fracture; and those with hip, vertebral, or extremity fracture are more likely to experience subsequent graft loss or mortality. These findings underscore that different fracture types may have different underlying etiologies and risks, and they should be approached accordingly. J Am Geriatr Soc 67:1680-1688, 2019.

Perioperative Low Arterial Oxygenation Is Associated With Increased Stroke Risk in Cardiac Surgery.

BACKGROUND: Both patient characteristics and intraoperative factors have been associated with a higher risk of stroke after cardiac surgery. We hypothesized that poor systemic oxygenation in the perioperative period is associated with increased risk of stroke following cardiopulmonary bypass. METHODS: In this study of 251 adult patients who underwent cardiopulmonary bypass procedures at a single center from 2003 to 2006, cases (patients with a postoperative stroke at least 24 hours after surgery) were matched 1:2 to controls without stroke. Minimum and average partial pressure of oxygen in arterial blood (PaO2) values, from arterial blood gas values during and up to 24 hours after surgery, were evaluated as continuous and categorical predictors. Conditional logistic regression models adjusted for potential confounders (demographics, comorbidities, and intraoperative variables) were used to evaluate associations between PaO2 variables and stroke status. RESULTS: Lower nadir PaO2 values were associated with postoperative stroke, with estimated odds of stroke increasing over 20% (adjusted odds ratio [OR], 1.23; 95% confidence interval [CI], 1.07-1.41) per 10 mm Hg lower nadir PaO2, and similarly increased odds of stroke per lower quartile of nadir PaO2 (OR, 1.60; 95% CI, 1.19-2.16). When average PaO2 was considered, odds of stroke was also increased (adjusted OR, 1.39 per lower quartile of mean PaO2; 95% CI, 1.05-1.83). Having a nadir PaO2 value in the lowest versus any other quartile was associated with an estimated 2.41-fold increased odds of stroke (95% CI, 1.22-4.78). Quartile of nadir but not average PaO2 results remained significant after adjustment for multiple comparisons. CONCLUSIONS: Odds of stroke after cardiac surgery are increased in patients with a low minimum PaO2 within 24 hours of surgery. Results should be validated in an independent cohort. Further characterizing the underlying etiology of hypoxic episodes will be important to improve patient outcomes.