Safety Factors and Patterns of Bicycle Trauma in a Tertiary Level 1 Trauma Center in Boston, Massachusetts: A Retrospective Review and Survey Study.

Objectives: Increasing bicycle ridership is accompanied by ongoing bicycle-related accidents in many urban cities. There is a need for improved understanding of patterns and risks of urban bicycle usage. We describe the injuries and outcomes of bicycle-related trauma in Boston, Massachusetts, and determine accident-related factors and behaviors associated with injury severity. Methods: We conducted a retrospective review via chart review of 313 bicycle-related injuries presenting to a Level 1 trauma center in Boston, Massachusetts. These patients were also surveyed regarding accident-related factors, personal safety practices, and road and environmental conditions during the accident. Results: Over half of all cyclists biked for commuting and recreational purposes (54%), used a road without a bike lane (58%), and a majority wore a helmet (91%). The most common injury pattern involved the extremities (42%) followed by head injuries (13%). Bicycling for commuting rather than recreation, cycling on a road with a dedicated bicycle lane, the absence of gravel or sand, and use of bicycle lights were all factors associated with decreased injury severity (p<0.05). After any bicycle injury, the number of miles cycled decreased significantly regardless of cycling purpose. Conclusion: Our results suggest that physical separation of cyclists from motor vehicles via bicycle lanes, regular cleaning of these lanes, and usage of bicycle lights are modifiable factors protective against injury and injury severity. Safe bicycling practices and understanding of factors involved in bicycle-related trauma can reduce injury severity and guide effective public health initiatives and urban planning.

A Physician Assistant Is Associated With Higher Patient Satisfaction With Outpatient Orthopedic Surgery.

Patient satisfaction is increasingly used to assess the quality of care and determine physician reimbursement. Patient characteristics influence patient satisfaction, but the effect of physician practice parameters on satisfaction has not been studied in detail. Outpatient satisfaction scores from 11,059 patients who rated 24 orthopedic surgeons from a single institution were studied. Practice-related parameters were collected in a provider-reported survey. Univariate logistic regressions were used to test the associations between each provider characteristic and the likelihood of receiving a 5-star rating on a selection of 16 Press Ganey patient satisfaction questions. The presence of a physician assistant in the clinic positively affected the 5-star rating for all but 1 of the patient satisfaction questions examined, including overall satisfaction (odds ratio [OR], 1.38; 95% CI, 1.03-1.85; P=.031); the likelihood of being recommended to others (OR, 1.57; 95% CI, 1.16-2.14; P=.004); and friendliness/courtesy (OR, 1.58; 95% CI, 1.17-2.13; P=.003). However, having a fellow or nurse practitioner in the clinic, treating children, productivity (measured as total relative value units), taking trauma call, and provider distance from home were not associated with higher scores for any of the Press Ganey patient satisfaction questions. Having a physician assistant in the clinic is an actionable, practice-specific characteristic that positively affects patient satisfaction on many levels and may ultimately improve the perception of care. [Orthopedics. 2022;45(5):e252-e256.].

Selecting the Next Class: The "Virtual Orthopaedic Rotation".

INTRODUCTION: When the COVID-19 pandemic forced the cancellation of visiting subinternships, we pivoted to create a virtual orthopaedic rotation (VOR). The purpose of this study was to assess the effect of the VOR on the residency selection process and determine the role of such a rotation in the future. METHODS: A committee was convened to create a VOR to replace visiting orthopaedic rotations for medical students who are interested in pursuing a career in orthopaedic surgery. The VOR was reviewed and sanctioned by our medical school, but no academic credit was granted. We conducted three 3-week VOR sessions. During each session, virtual rotators participated in regularly scheduled educational conferences and attended an invitation-only daily conference in the evenings that was designed for a medical student audience. In addition, students were paired with faculty and resident mentors in a structured mentorship program. Students' orthopaedic knowledge was assessed using prerotation and postrotation tests. RESULTS: From July to September 2020, 61 students from 37 distinct medical schools participated in the VOR. Notable improvements were observed in prerotation and postrotation orthopaedic knowledge test scores. In postrotation surveys, both students and faculty expressed high satisfaction with the curriculum but less certainty about how well they got to know each other. In the subsequent residency application cycle, 27.9% of the students who participated in the VOR were selected to interview, compared with 8.7% of the total application pool. DISCUSSION: The VOR was a valuable substitute for in-person clinical rotations during the COVID-19 pandemic. Although not likely to be a replacement for conventional away rotations, the VOR is a possible adjunct to in-person clinical rotations in the future.

Provider Personal and Demographic Characteristics and Patient Satisfaction in Orthopaedic Surgery.

INTRODUCTION: Patient satisfaction has increasingly been used to assess physician performance and quality of care. Although there is evidence that patient satisfaction is associated with patient-reported health outcomes and communication-related measures, there is debate over the use of patient satisfaction in reimbursement policy. Patient characteristics that influence satisfaction have been studied, but the effects of personal and demographic characteristics of physicians on patient satisfaction have yet to be explored. METHODS: Outpatient satisfaction scores from 11,059 patients who rated 25 orthopaedic surgeons from a single institution were studied. In this study, we sought to explore the relationship between nonmodifiable physician characteristics, such as sex and race, and patient satisfaction with outpatient orthopaedic surgery care, as expressed in the Press Ganey Satisfaction Scores. Univariate logistic regression models were used to test the associations between each provider characteristic and patient satisfaction on the Press Ganey patient satisfaction questionnaire. RESULTS: Three nonmodifiable physician personal and demographic characteristics were markedly associated with lower patient satisfaction scores across overall satisfaction, communication, and empathy domains: (1) female gender, (2) Asian ethnicity, and (3) being unmarried. Asian ethnicity reduced the odds of receiving a 5-star rating for likelihood to recommend the provider by nearly 40%, but none of these nonmodifiable physician personal and demographic characteristics affected the likelihood to recommend the practice. DISCUSSION: Sex, ethnicity, and marital status are nonmodifiable provider characteristics, each associated with markedly lower odds of receiving a 5-star rating on Press Ganey patient satisfaction survey. These data reveal inherent patient biases that negatively affect physician-patient interactions and may exacerbate the lack of diversity in orthopaedic surgery. More research is necessary before using patient satisfaction ratings to evaluate surgeons or as quality measures that affect reimbursement policies.

Do-Not-Resuscitate status is an independent risk factor for medical complications and mortality among geriatric patients sustaining hip fractures.

BACKGROUND: The purpose of this study was to compare outcomes after hip fracture surgery between DNR/DNI and full code cohorts to determine whether DNR/DNI status is an independent predictor of complications and mortality within one year. A significant number of geriatric hip fracture patients carry a code status designation of DNR/DNI (Do-Not-Resuscitate/Do-Not-Intubate). There is limited data addressing how this designation may influence prognosis. METHODS: A retrospective chart review of all geriatric hip fractures treated between 2002 and 2017 at a single level-I academic trauma center was performed. 434 patients were eligible for this study with 209 in the DNR/DNI cohort and 225 in the full code cohort. The independent variable was code-status and dependent variables included patient demographics, surgery performed, American Society of Anesthesiologists, score, Charlson Comorbidity Index, significant medical and surgical complications within one year of surgery, duration of follow-up by an orthopaedic surgeon, duration of follow-up by any physician, and mortality within 1 year of surgery. One-year complication rates were compared, and multiple logistic regression analyses were performed to analyze the relationship between independent and dependent variables. RESULTS: The DNR/DNI cohort experienced significantly more surgical complications compared to the full code cohort (14.8% vs 7.6%, p = 0.024). There was a significantly higher rate of medical complications and mortality in the DNR/DNI cohort (57.9% vs 36%, p < 0.001 and 19.1% vs 3.1%, p = 0.037, respectively). In the regression analysis, DNR/DNI status was an independent predictor of a medical complication (odds ratio 2.33, p = 0.004) and one-year mortality (odds ratio 9.69, p < 0.001), but was not for a surgical complication (OR 1.95, p = 0.892). CONCLUSIONS: In our analysis, DNR/DNI code status was an independent risk factor for postoperative medical complications and mortality within one year following hip fracture surgery. The results of our study highlight the need to recognize the relationship between DNR/DNI designation and medical frailty when treating hip fractures in the elderly population.

Precise immunomodulation of the M1 to M2 macrophage transition enhances mesenchymal stem cell osteogenesis and differs by sex.

OBJECTIVES: Up to 10% of fractures result in undesirable outcomes, for which female sex is a risk factor. Cellular sex differences have been implicated in these different healing processes. Better understanding of the mechanisms underlying bone healing and sex differences in this process is key to improved clinical outcomes. This study utilized a macrophage-mesenchymal stem cell (MSC) coculture system to determine: 1) the precise timing of proinflammatory (M1) to anti-inflammatory (M2) macrophage transition for optimal bone formation; and 2) how such immunomodulation was affected by male versus female cocultures. METHODS: A primary murine macrophage-MSC coculture system was used to demonstrate the optimal transition time from M1 to M2 (polarized from M1 with interleukin (IL)-4) macrophages to maximize matrix mineralization in male and female MSCs. Outcome variables included Alizarin Red staining, alkaline phosphatase (ALP) activity, and osteocalcin protein secretion. RESULTS: We found that 96 hours of M1 phenotype in male cocultures allowed for maximum matrix mineralization versus 72 hours in female cocultures. ALP activity and osteocalcin secretion were also enhanced with the addition of IL-4 later in male versus female groups. The sex of the cells had a statistically significant effect on the optimal IL-4 addition time to maximize osteogenesis. CONCLUSION: These results suggest that: 1) a 72- to 96-hour proinflammatory environment is critical for optimal matrix mineralization; and 2) there are immunological differences in this coculture environment due to sex. Optimizing immunomodulation during fracture healing may enhance and expedite the bone regeneration response. These findings provide insight into precise immunomodulation for enhanced bone healing that is sex-specific.Cite this article: K. Nathan, L. Y. Lu, T. Lin, J. Pajarinen, E. Jämsen, J-F. Huang, M. Romero-Lopez, M. Maruyama, Y. Kohno, Z. Yao, S. B. Goodman. Precise immunomodulation of the M1 to M2 macrophage transition enhances mesenchymal stem cell osteogenesis and differs by sex. Bone Joint Res 2019;8:481-488. DOI: 10.1302/2046-3758.810.BJR-2018-0231.R2.

Can Patients Forecast Their Postoperative Disability and Pain?

BACKGROUND: Forecasting is a construct in which experiences and beliefs inform a projection of future outcomes. Current efforts to predict postoperative patient-reported outcome measures such as risk-stratifying models, focus on studying patient, surgeon, or facility variables without considering the mindset of the patient. There is no evidence assessing the association of a patient's forecasted postoperative disability with realized postoperative disability. Patient-forecasted disability could potentially be used as a tool to predict postoperative disability. QUESTIONS/PURPOSES: (1) Do patient-forecasted disability and pain correlate with patient-realized disability and pain after hand surgery? (2) What other factors are associated with patient ability to forecast disability and pain? METHODS: We completed a prospective, longitudinal study to assess the association between forecasted and realized postoperative pain and disability as a predictive tool. One hundred eighteen patients of one hand/upper extremity surgeon were recruited from November 2016 to February 2018. Inclusion criteria for the study were patients undergoing hand or upper extremity surgery, older than 18 years of age, and English fluency and literacy. We enrolled 118 patients; 32 patients (27%) dropped out as a result of incomplete postoperative questionnaires. The total number of patients eligible was not tracked. Eighty-six patients completed the preoperative and postoperative questionnaires. Exclusion criteria included patients unable to give informed consent, children, patients with dementia, and nonEnglish speakers. Before surgery, patients completed a questionnaire that asked them to forecast their upper extremity disability (DASH [the shortened Disabilities of the Arm, Shoulder and Hand] [QuickDASH]) and pain VAS (pain from 0 to 10) for 2 weeks after their procedure. The questionnaire also queried the following psychologic factors as explanatory variables, in addition to other demographic and socioeconomic variables: the General Self Efficacy Scale, the Pain Catastrophizing Scale, and the Patient Health Questionnaire Depression Scale. At the 2-week followup appointment, patients completed the QuickDASH and pain VAS to assess their realized disability and pain scores. Bivariate analysis was used to test the association of forecasted and realized disability and pain reporting Pearson correlation coefficients. Unpaired t-tests were performed to test the association of demographic variables (for example, men vs women) and the association of forecasted and realized disability and pain levels. One-way analysis of variance was used for variables with multiple groups (for example, annual salary and ethnicity). All p values < 0.05 were considered statistically significant. RESULTS: Forecasted postoperative disability was moderately correlated with realized postoperative disability (r = 0.59; p < 0.001). Forecasted pain was weakly correlated with realized postoperative pain (r = 0.28; p = 0.011). A total of 47% of patients (n = 40) were able to predict their disability score within the MCID of their realized disability score. Symptoms of depression also correlated with increased realized postoperative disability (r = 0.37; p < 0.001) and increased realized postoperative pain (r = 0.42; p < 0.001). Catastrophic thinking was correlated with increased realized postoperative pain (r = 0.31; p = 0.004). Patients with symptoms of depression realized greater pain postoperatively than what they forecasted preoperatively (r = -0.24; p = 0.028), but there was no association between symptoms of depression and patients' ability to forecast disability (r = 0.2; p = 0.058). Patient age was associated with a patient's ability to forecast disability (r = .27; p = 0.011). Catastrophic thinking, self-efficacy, and number of prior surgical procedures were not associated with a patient's ability to forecast their postoperative disability or pain. CONCLUSIONS: Patients undergoing hand surgery can moderately forecast their postoperative disability. Surgeons can use forecasted disability to identify patients who may experience greater disability compared with benchmarks, for example, forecast and experience high QuickDASH scores after surgery, and inform preoperative discussions and interventions focused on expectation management, resilience, and mindset. LEVEL OF EVIDENCE: Level III, prognostic study.

The Role of Patient Research in Patient Trust in Their Physician.

PURPOSE: Trust is foundational to the patient-physician relationship. However, there is limited information on the patient characteristics and behaviors that are related to patient trust. We investigated whether the time patients spend researching their physician and/or symptoms before a clinic visit was correlated with patient trust in their hand surgeon. METHODS: We conducted a prospective study of new patients (n = 134) who presented to a hand surgery clinic. We tested the null hypothesis that time spent researching the physician or symptom does not correlate with physician trust. Secondarily, we tested the association of a maximizing personality (a decision-making personality type defined as one who exhaustively searches for the "best option" as opposed to a "satisficer" who settles for the "good enough" decision) with time spent researching the hand surgeon and patient symptoms, general self-efficacy (one's ability to manage adversity), and patient trust. Patients completed a questionnaire assessing demographics, patient researching behavior, general self-efficacy (GSE-6), maximizing personality (Maximization Short Form), and physician trust (Trust in Physician Form). RESULTS: The average age of our cohort was 50 ± 17 years, and men and women were equally represented. Patients spent more time researching their symptoms (median, 60 min; range, 5-1,201 min) than they did researching their physician (median, 20 min; range, 1-1,201 min). There was no correlation between time spent by patients seeking information on their hand surgeon and/or symptoms with patient trust in their physician. However, female patients were significantly more trusting of their physician than male patients. CONCLUSIONS: Most patients research their symptoms before clinic, whereas about half research their physicians before meeting them. Time spent seeking information before clinic was not correlated with patient trust in their physician. However, in our study, female patients were more likely to trust their hand surgeon than male patients. Thus, modifying physician behavior rather than patient characteristics may be a stronger driver of patient trust. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Joint replacement surgery in homeless veterans.

Total joint arthroplasty (TJA) in a homeless patient is generally considered contraindicated. Here, we report our known medical and social (housing and employment) results of homeless veterans who had TJA. Thirty-seven TJAs were performed on 33 homeless patients (31 men) at our hospital between November 2000 and March 2014. This was 1.2% of all TJAs. Average age was 54 years. Average hospital stay was 4.1 days. There were no major inpatient complications. Thirty-four cases had at least 1-year follow-up in any clinic within the Veterans Affairs health care system. There were no known surgery-related reoperations or readmissions. At final follow-up, 24 patients had stable housing and 9 were employed. The extensive and coordinated medical and social services that were provided to veterans from the Department of Veterans Affairs contributed to our positive results.

Inflammation, ageing, and bone regeneration.

SUMMARY: Bone healing involves complex biological pathways and interactions among various cell types and microenvironments. Among them, the monocyte-macrophage-osteoclast line-age and the mesenchymal stem cell-osteoblast lineage are critical, in addition to an initial inflammatory microenvironment. These cellular interactions induce the necessary inflammatory milieu and provide the cells for bone regeneration and immune modulation. Increasing age is accompanied with a rise in the basal state of inflammation, potentially impairing osteogenesis. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: Translational research has shown multiple interactions between inflammation, ageing, and bone regeneration. This review presents recent, relevant considerations regarding the effects of inflammation and ageing on bone healing.

Pro-inflammatory M1 macrophages promote Osteogenesis by mesenchymal stem cells via the COX-2-prostaglandin E2 pathway.

Bone fractures are among the most common orthopaedic problems that affect individuals of all ages. Immediately after injury, activated macrophages dynamically contribute to and regulate an acute inflammatory response that involves other cells at the injury site, including mesenchymal stem cells (MSCs). These macrophages and MSCs work in concert to modulate bone healing. In this study, we co-cultured undifferentiated M0, pro-inflammatory M1, and anti-inflammatory M2 macrophages with primary murine MSCs in vitro to determine the cross-talk between polarized macrophages and MSCs and their effects on osteogenesis. After 4 weeks of co-culture, MSCs grown with macrophages, especially M1 macrophages, had enhanced bone mineralization compared to MSCs grown alone. The level of bone formation after 4 weeks of culture was closely associated with prostaglandin E2 (PGE2) secretion early in osteogenesis. Treatment with celecoxib, a cyclooxygenase-2 (COX-2) selective inhibitor, significantly reduced bone mineralization in all co-cultures but most dramatically in the M1-MSC co-culture. We also found that the presence of macrophages reduced the secretion of osteoprotegerin (OPG), the decoy RANKL receptor, suggesting that macrophages may indirectly modulate osteoclast activity in addition to enhancing bone formation. Taken together, these findings suggest that an initial pro-inflammatory phase modulated by M1 macrophages promotes osteogenesis in MSCs via the COX-2-PGE2 pathway. Understanding the complex interactions between macrophages and MSCs provide opportunities to optimize bone healing and other regenerative processes via modulation of the inflammatory response. This study provides one possible biological mechanism for the adverse effects of non-steroidal anti-inflammatory drugs on fracture healing and bone regeneration. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2378-2385, 2017.

A triple helix stabilizes the 3' ends of long noncoding RNAs that lack poly(A) tails.

The MALAT1 (metastasis-associated lung adenocarcinoma transcript 1) locus is misregulated in many human cancers and produces an abundant long nuclear-retained noncoding RNA. Despite being transcribed by RNA polymerase II, the 3' end of MALAT1 is produced not by canonical cleavage/polyadenylation but instead by recognition and cleavage of a tRNA-like structure by RNase P. Mature MALAT1 thus lacks a poly(A) tail yet is expressed at a level higher than many protein-coding genes in vivo. Here we show that the 3' ends of MALAT1 and the MEN ß long noncoding RNAs are protected from 3'-5' exonucleases by highly conserved triple helical structures. Surprisingly, when these structures are placed downstream from an ORF, the transcript is efficiently translated in vivo despite the lack of a poly(A) tail. The triple helix therefore also functions as a translational enhancer, and mutations in this region separate this translation activity from simple effects on RNA stability or transport. We further found that a transcript ending in a triple helix is efficiently repressed by microRNAs in vivo, arguing against a major role for the poly(A) tail in microRNA-mediated silencing. These results provide new insights into how transcripts that lack poly(A) tails are stabilized and regulated and suggest that RNA triple-helical structures likely have key regulatory functions in vivo.