A warm Neptune's methane reveals core mass and vigorous atmospheric mixing.

Observations of transiting gas giant exoplanets have revealed a pervasive depletion of methane1,2,3,4, which has only recently been identified atmospherically5,6. The depletion is thought to be maintained by disequilibrium processes such as photochemistry or mixing from a hotter interior7,8,9. However, the interiors are largely unconstrained along with the vertical mixing strength and only upper limits on the CH4 depletion have been available. The warm Neptune WASP-107 b stands out among exoplanets with an unusually low density, reported low core mass10, and temperatures amenable to CH4 though previous observations have yet to find the molecule2,4. Here we present a JWST NIRSpec transmission spectrum of WASP-107 b which shows features from both SO2 and CH4 along with H2O, CO2, and CO. We detect methane with 4.2σ significance at an abundance of 1.0±0.5 ppm, which is depleted by 3 orders of magnitude relative to equilibrium expectations. Our results are highly constraining for the atmosphere and interior, which indicate the envelope has a super-solar metallicity of 43±8× solar, a hot interior with an intrinsic temperature of Tint=460±40 K, and vigorous vertical mixing which depletes CH4 with a diffusion coefficient of Kzz = 1011.6±0.1 cm2/s. Photochemistry has a negligible effect on the CH4 abundance, but is needed to account for the SO2. We infer a core mass of 11.5 - 3.6 + 3.0 M⊕, which is much higher than previous upper limits10, releasing a tension with core-accretion models11.

Hip Fracture Repair by the Post-Call Surgeon: A Multicenter Retrospective Review.

INTRODUCTION: The purpose of this study was to evaluate surgeons' ability to perform or supervise a standard operation with agreed-upon radiologic parameters after being on call. METHODS: We reviewed a consecutive series of patients with intertrochanteric hip fractures treated with a fixed angle device at 9 centers and compared corrected tip-apex distance and reduction quality for post-call surgeons versus those who were not. Subgroup analyses included surgeons who operated the night before versus not and attending-only versus resident involved cases. Secondary outcomes included union and perioperative complications. RESULTS: One thousand seven hundred fourteen patients were of average age 77 years. Post-call surgeons treated 823 patients and control surgeons treated 891. Surgical corrected tip-apex distance did not differ between groups: on-call 18 mm versus control 18 mm (P = 0.59). The Garden indices were 160° on the AP and 179° on the lateral in both groups. In 66 cases performed by surgeons who operated the night before, the TAD was 17 mm. No difference was noted in corrected tip-apex distance with and without resident involvement (P = 0.101). No difference was observed in pooled fracture-related complications (P = 0.23). CONCLUSION: Post-call surgeons demonstrated no difference in quality and no increase in complications when performing hip fracture repair the next day compared with surgeons who were not on call.

Computer-assisted Navigation in Lumbar Spine Instrumented Fusions: Comparison of In-hospital and 30-Day Postoperative Complications With Nonnavigated Fusions in a National Database.

OBJECTIVE: To compare in-hospital and 30-day postoperative complications for lumbar spine operations with and without use of computer-assisted navigation. METHODS: Patients who underwent 1-level to 3-level lumbar spinal instrumentation and fusions 2011 to 2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Emergent procedures and patients aged younger than 18 years were excluded. Patients whose surgery involved the use of computer-assisted navigation were propensity score matched 1:4 based on preoperative demographics and comorbidities to operations without the use of navigation. Multivariate analysis was done to compare postoperative complications. RESULTS: In total, 8,500 patients (average age: 60.7 ± 12.9, male 3,866, female 4,634) were analyzed (1,700 navigation, 6,800 Non-Navigated). Operations with navigation had significantly fewer overall complications (24% vs. 27%, P = 0.008; odds ratio [OR] = 0.83; CI = 0.73 to 0.95), fewer minor complications (20% vs. 24%, P = 0.002; OR = 0.80; CI = 0.70 to 0.91), fewer blood transfusions (17% v. 20%, P = 0.013; OR = 0.82; CI = 0.71 to 0.95), more wound dehiscences (0.4% vs. 0.8%, P = 0.022; OR = 2.16; CI = 1.12,4.19), and shorter average lengths of hospital stays (4.8 ± 4.8 vs. 5.1 ± 5.8 days, P = 0.01). Operations with computer navigation had significantly longer average surgical times (247 ± 129 vs 221 ± 115 minutes, P < 0.001). No significant differences were observed in 30-day revision rates, readmissions, and mortality. CONCLUSION: Although use of computer-assisted navigation in short-segment lumbar spine fusions (1 to 3 levels) did not decrease revision rates for screw misplacement within 30 days postoperatively, it independently reduced the frequency of blood transfusions and minor complications and decreased hospital lengths of stay compared with operations without navigation. These benefits came at the expense of increased surgical times and wound dehiscences within 30 days postoperatively. Given the inherent limitations of large national databases, these results warrant confirmation through prospective, multicenter investigations.

Carpal Tunnel Release Performed during Distal Radius Fracture Surgery.

Background Carpal tunnel release (CTR) may be concomitantly performed along with distal radius fracture open reduction internal fixation (DRF ORIF) to prevent carpal tunnel syndrome; however, there is little to no literature investigating the rate, risk factors, and complications associated with CTR. Questions/Purposes The purpose was to determine (1) the rate of CTR performed at time of DRF ORIF, (2) factors associated with CTR, and (3) whether CTR was associated with any complications. Patients and Methods In this case-control study, adult patients who underwent DRF ORIF from 2014 to 2018 were identified from a national surgical database. Two cohorts were analyzed, (1) patients with CTR and (2) patients without CTR. Preoperative characteristics and postoperative complications were compared with determine factors associated with CTR. Results Of the 18,466 patients, 769 (4.2%) had CTR. Rates of CTR in patients with intra-articular fractures with two or three fragments were significantly higher than the rate of CTR for patients with extra-articular fractures. Underweight patients underwent CTR at a significantly lower rate compared with overweight and obese patients. The American Society of Anesthesiologists ≥3 was associated with a higher rate of CTR. Male and older patients were less likely to have CTR. Conclusion The rate of CTR at time of DRF ORIF was 4.2%. Intra-articular fractures with multiple fragments were strongly associated with CTR at time of DRF ORIF, while being underweight, elderly, and male were associated with lower rates of CTR. These findings should be considered when developing clinical guidelines to assess the need for CTR in patients undergoing DRF ORIF. This is a retrospective case control study and reflects level of evidence III.

A broadband thermal emission spectrum of the ultra-hot Jupiter WASP-18b.

Close-in giant exoplanets with temperatures greater than 2,000 K ('ultra-hot Jupiters') have been the subject of extensive efforts to determine their atmospheric properties using thermal emission measurements from the Hubble Space Telescope (HST) and Spitzer Space Telescope1-3. However, previous studies have yielded inconsistent results because the small sizes of the spectral features and the limited information content of the data resulted in high sensitivity to the varying assumptions made in the treatment of instrument systematics and the atmospheric retrieval analysis3-12. Here we present a dayside thermal emission spectrum of the ultra-hot Jupiter WASP-18b obtained with the NIRISS13 instrument on the JWST. The data span 0.85 to 2.85 µm in wavelength at an average resolving power of 400 and exhibit minimal systematics. The spectrum shows three water emission features (at >6σ confidence) and evidence for optical opacity, possibly attributable to H-, TiO and VO (combined significance of 3.8σ). Models that fit the data require a thermal inversion, molecular dissociation as predicted by chemical equilibrium, a solar heavy-element abundance ('metallicity', [Formula: see text] times solar) and a carbon-to-oxygen (C/O) ratio less than unity. The data also yield a dayside brightness temperature map, which shows a peak in temperature near the substellar point that decreases steeply and symmetrically with longitude towards the terminators.

Photochemically produced SO2 in the atmosphere of WASP-39b.

Photochemistry is a fundamental process of planetary atmospheres that regulates the atmospheric composition and stability1. However, no unambiguous photochemical products have been detected in exoplanet atmospheres so far. Recent observations from the JWST Transiting Exoplanet Community Early Release Science Program2,3 found a spectral absorption feature at 4.05 µm arising from sulfur dioxide (SO2) in the atmosphere of WASP-39b. WASP-39b is a 1.27-Jupiter-radii, Saturn-mass (0.28 MJ) gas giant exoplanet orbiting a Sun-like star with an equilibrium temperature of around 1,100 K (ref. 4). The most plausible way of generating SO2 in such an atmosphere is through photochemical processes5,6. Here we show that the SO2 distribution computed by a suite of photochemical models robustly explains the 4.05-µm spectral feature identified by JWST transmission observations7 with NIRSpec PRISM (2.7σ)8 and G395H (4.5σ)9. SO2 is produced by successive oxidation of sulfur radicals freed when hydrogen sulfide (H2S) is destroyed. The sensitivity of the SO2 feature to the enrichment of the atmosphere by heavy elements (metallicity) suggests that it can be used as a tracer of atmospheric properties, with WASP-39b exhibiting an inferred metallicity of about 10× solar. We further point out that SO2 also shows observable features at ultraviolet and thermal infrared wavelengths not available from the existing observations.

Early Release Science of the exoplanet WASP-39b with JWST NIRISS.

The Saturn-mass exoplanet WASP-39b has been the subject of extensive efforts to determine its atmospheric properties using transmission spectroscopy1-4. However, these efforts have been hampered by modelling degeneracies between composition and cloud properties that are caused by limited data quality5-9. Here we present the transmission spectrum of WASP-39b obtained using the Single-Object Slitless Spectroscopy (SOSS) mode of the Near Infrared Imager and Slitless Spectrograph (NIRISS) instrument on the JWST. This spectrum spans 0.6-2.8 µm in wavelength and shows several water-absorption bands, the potassium resonance doublet and signatures of clouds. The precision and broad wavelength coverage of NIRISS/SOSS allows us to break model degeneracies between cloud properties and the atmospheric composition of WASP-39b, favouring a heavy-element enhancement ('metallicity') of about 10-30 times the solar value, a sub-solar carbon-to-oxygen (C/O) ratio and a solar-to-super-solar potassium-to-oxygen (K/O) ratio. The observations are also best explained by wavelength-dependent, non-grey clouds with inhomogeneous coverageof the planet's terminator.

Early Release Science of the exoplanet WASP-39b with JWST NIRSpec G395H.

Measuring the abundances of carbon and oxygen in exoplanet atmospheres is considered a crucial avenue for unlocking the formation and evolution of exoplanetary systems1,2. Access to the chemical inventory of an exoplanet requires high-precision observations, often inferred from individual molecular detections with low-resolution space-based3-5 and high-resolution ground-based6-8 facilities. Here we report the medium-resolution (R ≈ 600) transmission spectrum of an exoplanet atmosphere between 3 and 5 µm covering several absorption features for the Saturn-mass exoplanet WASP-39b (ref. 9), obtained with the Near Infrared Spectrograph (NIRSpec) G395H grating of JWST. Our observations achieve 1.46 times photon precision, providing an average transit depth uncertainty of 221 ppm per spectroscopic bin, and present minimal impacts from systematic effects. We detect significant absorption from CO2 (28.5σ) and H2O (21.5σ), and identify SO2 as the source of absorption at 4.1 µm (4.8σ). Best-fit atmospheric models range between 3 and 10 times solar metallicity, with sub-solar to solar C/O ratios. These results, including the detection of SO2, underscore the importance of characterizing the chemistry in exoplanet atmospheres and showcase NIRSpec G395H as an excellent mode for time-series observations over this critical wavelength range10.

Early Release Science of the exoplanet WASP-39b with JWST NIRCam.

Measuring the metallicity and carbon-to-oxygen (C/O) ratio in exoplanet atmospheres is a fundamental step towards constraining the dominant chemical processes at work and, if in equilibrium, revealing planet formation histories. Transmission spectroscopy (for example, refs. 1,2) provides the necessary means by constraining the abundances of oxygen- and carbon-bearing species; however, this requires broad wavelength coverage, moderate spectral resolution and high precision, which, together, are not achievable with previous observatories. Now that JWST has commenced science operations, we are able to observe exoplanets at previously uncharted wavelengths and spectral resolutions. Here we report time-series observations of the transiting exoplanet WASP-39b using JWST's Near InfraRed Camera (NIRCam). The long-wavelength spectroscopic and short-wavelength photometric light curves span 2.0-4.0 micrometres, exhibit minimal systematics and reveal well defined molecular absorption features in the planet's spectrum. Specifically, we detect gaseous water in the atmosphere and place an upper limit on the abundance of methane. The otherwise prominent carbon dioxide feature at 2.8 micrometres is largely masked by water. The best-fit chemical equilibrium models favour an atmospheric metallicity of 1-100-times solar (that is, an enrichment of elements heavier than helium relative to the Sun) and a substellar C/O ratio. The inferred high metallicity and low C/O ratio may indicate significant accretion of solid materials during planet formation (for example, refs. 3,4,) or disequilibrium processes in the upper atmosphere (for example, refs. 5,6).

Higher-Than-Expected Rates of Distal Radioulnar Joint Fixation in Radial Shaft Fractures: Location of Fracture Matters.

BACKGROUND: The purpose of this study was to evaluate rates of distal radioulnar joint (DRUJ) fixation based on location of the radial shaft fracture and risk factors associated with postoperative complications following radial shaft open reduction internal fixation (ORIF). METHODS: Adult patients who underwent isolated radial shaft ORIF from 2014 to 2018 were identified from American College of Surgeons National Surgical Quality Improvement Program database and stratified by fracture location and by the presence or absence of DRUJ fixation. Preoperative patient characteristics and postoperative complications were compared to determine risk factors associated with DRUJ fixation. RESULTS: We identified 1517 patients who underwent isolated radial shaft ORIF, of which 396 (26.1%) underwent DRUJ fixation. Preoperative patient characteristics and postoperative complications were similar between cohorts. Distal radioulnar joint fixation was performed in 50 (30.7%) of 163 distal radial shaft fractures, 191 (21.8%) of 875 midshaft fractures, and 3 (13.0%) of 23 proximal shaft fractures (P = .025). Risk factors for patients readmitted include male sex (odds ratio [OR] = 12.76, P = .009) and older age (OR = 4.99, P = .035). Risk factors for patients with any postoperative complication include dependent functional status (OR = 6.78, P = .02), older age (50-69 vs <50) (OR = 2.73, P = .05), and American Society of Anesthesiologists (ASA) ≥3 (OR = 2.45, P = .047). CONCLUSIONS: The rate of DRUJ fixation in radial shaft ORIF exceeded previously reported rates of concomitant DRUJ injury, especially among distal radial shaft fractures. More distally located radial shaft fractures are significantly associated with higher rates of DRUJ fixation. Male sex is a risk factor for readmission, whereas dependent functional status, older age, and ASA ≥3 are risk factors for postoperative complications.

Detecting upper extremity native joint dislocations using deep learning: A multicenter study.

OBJECTIVE: Joint dislocations are orthopedic emergencies that require prompt intervention. Automatic identification of these injuries could help improve timely patient care because diagnostic delays increase the difficulty of reduction. In this study, we developed convolutional neural networks (CNNs) to detect elbow and shoulder dislocations, and tested their generalizability on external datasets. METHODS: We collected 106 elbow radiographs (53 with dislocation [50 %]) and 140 shoulder radiographs (70 with dislocation [50 %]) from a level-1 trauma center. After performing 24× data augmentation on training/validation data, we trained multiple CNNs to detect elbow and shoulder dislocations, and also evaluated the best-performing models using external datasets from an external hospital and online radiology repositories. To examine CNN decision-making, we generated class activation maps (CAMs) to visualize areas of images that contributed the most to model decisions. RESULTS: On all internal test sets, CNNs achieved AUCs >0.99, and on all external test sets, CNNs achieved AUCs >0.97. CAMs demonstrated that the CNNs were focused on relevant joints in decision-making regardless of whether or not dislocations were present. CONCLUSION: Joint dislocations in both shoulders and elbows were readily identified with high accuracy by CNNs with excellent generalizability to external test sets. These findings suggest that CNNs could expedite access to intervention by assisting in diagnosing dislocations.

Detecting total hip arthroplasty dislocations using deep learning: clinical and Internet validation.

OBJECTIVE: Periprosthetic dislocations of total hip arthroplasty (THA) are time-sensitive injuries, as the longer diagnosis and treatment are delayed, the more difficult they are to reduce. Automated triage of radiographs with dislocations could help reduce these delays. We trained convolutional neural networks (CNNs) for the detection of THA dislocations, and evaluated their generalizability by evaluating them on external datasets. METHODS: We used 357 THA radiographs from a single hospital (185 with dislocation [51.8%]) to develop and internally test a variety of CNNs to identify THA dislocation. We performed external testing of these CNNs on two datasets to evaluate generalizability. CNN performance was evaluated using area under the receiving operating characteristic curve (AUROC). Class activation mapping (CAM) was used to create heatmaps of test images for visualization of regions emphasized by the CNNs. RESULTS: Multiple CNNs achieved AUCs of 1 for both internal and external test sets, indicating good generalizability. Heatmaps showed that CNNs consistently emphasized the THA for both dislocated and located THAs. CONCLUSION: CNNs can be trained to recognize THA dislocation with high diagnostic performance, which supports their potential use for triage in the emergency department. Importantly, our CNNs generalized well to external data from two sources, further supporting their potential clinical utility.

Can images crowdsourced from the internet be used to train generalizable joint dislocation deep learning algorithms?

OBJECTIVE: Deep learning has the potential to automatically triage orthopedic emergencies, such as joint dislocations. However, due to the rarity of these injuries, collecting large numbers of images to train algorithms may be infeasible for many centers. We evaluated if the Internet could be used as a source of images to train convolutional neural networks (CNNs) for joint dislocations that would generalize well to real-world clinical cases. METHODS: We collected datasets from online radiology repositories of 100 radiographs each (50 dislocated, 50 located) for four joints: native shoulder, elbow, hip, and total hip arthroplasty (THA). We trained a variety of CNN binary classifiers using both on-the-fly and static data augmentation to identify the various joint dislocations. The best-performing classifier for each joint was evaluated on an external test set of 100 corresponding radiographs (50 dislocations) from three hospitals. CNN performance was evaluated using area under the ROC curve (AUROC). To determine areas emphasized by the CNN for decision-making, class activation map (CAM) heatmaps were generated for test images. RESULTS: The best-performing CNNs for elbow, hip, shoulder, and THA dislocation achieved high AUROCs on both internal and external test sets (internal/external AUC): elbow (1.0/0.998), hip (0.993/0.880), shoulder (1.0/0.993), THA (1.0/0.950). Heatmaps demonstrated appropriate emphasis of joints for both located and dislocated joints. CONCLUSION: With modest numbers of images, radiographs from the Internet can be used to train clinically-generalizable CNNs for joint dislocations. Given the rarity of joint dislocations at many centers, online repositories may be a viable source for CNN-training data.

UV absorption by silicate cloud precursors in ultra-hot Jupiter WASP-178b.

Aerosols have been found to be nearly ubiquitous in substellar atmospheres1-3. The precise temperature at which these aerosols begin to form in exoplanets has yet to be observationally constrained. Theoretical models and observations of muted spectral features indicate that silicate clouds play an important role in exoplanets between at least 950 and 2,100 K (ref. 4). Some giant planets, however, are thought to be hot enough to avoid condensation altogether5,6. Here we report the near-ultraviolet transmission spectrum of the ultra-hot Jupiter WASP-178b (approximately 2,450 K), which exhibits substantial absorption. Bayesian retrievals indicate the presence of gaseous refractory species containing silicon and magnesium, which are the precursors to condensate clouds at lower temperatures. SiO, in particular, has not previously, to our knowledge, been detected in exoplanets, but the presence of SiO in WASP-178b is consistent with theoretical expectations as the dominant Si-bearing species at high temperatures. These observations allow us to re-interpret previous observations of HAT-P-41b and WASP-121b that did not consider SiO, to suggest that silicate cloud formation begins on exoplanets with equilibrium temperatures between 1,950 and 2,450 K.

Peripheral Nerve Blocks Associated With Shorter Length of Stay Without Increasing Readmission Rate for Ankle Open Reduction Internal Fixation in the Outpatient Setting: A Propensity-Matched Analysis.

Peripheral nerve blocks (PNB) have become an important modality for pain management in ankle fracture surgery. Previous studies have reported their efficacy, but concerns with rebound pain and readmissions have been cited as possible deterrents. The purpose of this study was to evaluate the effects of PNB on hospital length of stay (LOS), narcotic intake, visual analog scale (VAS) for pain, and associated complications in patients undergoing outpatient ankle open reduction internal fixation (ORIF). Adult patients undergoing ankle ORIF were matched 2:1 (no block:block) using propensity-score matching. Preoperative patient characteristics and postoperative outcomes were compared between cohorts. VAS and total narcotic intake were evaluated for each of the first 3 postoperative 8-hour shifts. Narcotic medication was converted to morphine milligram equivalents (MME). Thirty-two patients who received PNB were matched to 64 patients who did not. The PNB group had lower VAS and MME during each of the 8-hour shifts after surgery: 0 to 8 hours (VAS 1.8 vs 6.3; MME 10.6 vs 77.9; p < .001), 8 to 16 hours (VAS 1.2 vs 5.9; MME 9.2 vs 28.2; p < .001), 16 to 24 hours (VAS 3.7 vs 6.2; MME 13.2 vs 24.2; p = .006 and 0.019). PNB had a shorter LOS (average 16.7 hours vs 26.8 hours; p < .001). There were no differences in rates of ED presentations after discharge, hospital readmissions, or complications between cohorts. Peripheral nerve blocks after ankle ORIF are associated with shorter hospital LOS, lower VAS, and reduced narcotic intake without increasing rates of ED visits, hospital readmissions, or complications.

Authorship Proliferation of Research Articles in Top 10 Orthopaedic Journals: A 70-Year Analysis.

INTRODUCTION: Scholarly impact has been used to measure faculty productivity and academic contribution throughout academia. Traditionally, the number of articles authored has been the primary metric for scholarly impact regarding academic promotion and reputation. We hypothesize that over time, the nature of authorship has evolved to include more authors per research article throughout the history of orthopaedic literature. METHODS: Bibliometric data for all original research article abstracts were extracted from PubMED for the 10 highest rated H5-index orthopaedic clinical journals ("American Journal of Sports Medicine," "Journal of Bone and Joint Surgery American Volume," "Clinical Orthopaedics and Related Research "Spine," "Knee Surgery, Sports Traumatology, Arthroscopy," "Journal of Arthroplasty," "Arthroscopy," "The Spine Journal," "European Spine Journal," and "Journal of Bone and Joint Surgery British Volume/Bone & Joint Journal"). The number of authors per article was then analyzed over time using the Cochran-Armitage trend test. RESULTS: A total of 106,529 original articles were analyzed over a 70-year period. The number of authors increased significantly over time from a mean of 1.4 authors (SD: 0.62) in 1946 to 5.7 authors (SD: 3.1) in 2019, representing an average relative increase of 4.3% per year (P < 0.05). The three oldest journals had the lowest average authors (Journal of Bone and Joint Surgery Am Volume: 1946, mean 3.7 authors [SD: eight]; Journal of Bone and Joint Surgery Br Volume/Bone & Joint Journal: 1948, mean: 3.6 authors [SD: 7.5]; Clinical Orthopaedics and Related Research: 1963, mean 3.3 authors [SD: 2.9]). The three newest journals had the highest average authors (European Spine Journal: 1992, mean 5.3 authors [SD: 3.3]; Knee Surgery, Sports Traumatology, Arthroscopy: 1993, mean 5.5 authors [SD: 6.7 authors; The Spine Journal: 2003, mean 5.2 authors [SD: 3.6]). DISCUSSION: Original research articles published in orthopaedic academic journals have experienced an increase in authorship over time. Although our data cannot explain what has driven this change, increasing cooperation between collaborators may represent less contribution per author over time.

Infection and Mechanical Complications Are Risk Factors for New Diagnosis of a Mental Health Disorder After Total Joint Arthroplasty.

BACKGROUND: Prior studies have demonstrated that depression is an independent risk factor for developing a prosthetic joint infection (PJI) after total joint arthroplasty (TJA). To our knowledge, there is no literature examining whether PJI or aseptic failure increases the risk of developing a new mental health diagnosis. METHODS: PearlDiver Patient Database (Colorado Springs, CO) was used to identify 80,826 patients who underwent TJA without a pre-existing diagnosis of depression, anxiety, a stress and/or adjustment disorder, and/or current use of a selective serotonin reuptake inhibitor within the year prior to surgery. The odds of developing a new mental health issue or being prescribed a selective serotonin reuptake inhibitor within 1 year of an uncomplicated TJA was compared to those who developed PJI or mechanical failure within 90 days after TJA as well as to those who subsequently underwent revision surgery within 30 days of either complication using Fisher's exact test and Baptista-Pike. RESULTS: A total of 6474 (8%) patients were diagnosed with a new mental health issue after TJA. PJI or mechanical failure led to significantly higher odds of new diagnoses with an odds ratio of 1.67 (95% confidence interval = 1.26, 2.22) and 1.57 (1.24, 2.00), respectively. Undergoing revision surgery for PJI or mechanical failure increased the odds of developing a new mental health diagnosis to 2.10 (1.29, 3.42) and 2.24 (1.36, 3.72), respectively. There was no significant difference comparing those who developed PJI vs those who sustained mechanical complications. CONCLUSION: Patients who sustain complications after TJA are at increased odds of receiving a new mental health diagnosis, an effect further amplified if revision surgery is required.

Recognizing Isolated Ulnar Fractures as Potential Markers for Intimate Partner Violence.

PURPOSE: This study aimed to assess the incidence of intimate partner violence (IPV) in women with isolated ulnar fractures and compare the injury characteristics in victims of IPV with those who sustained the same fractures due to other causes. METHODS: Electronic health records from three level I trauma centers were queried to identify a cohort of women, aged 18 to 50, sustaining isolated ulnar fractures from 2005 to 2019. Radiographs were reviewed for fracture location, comminution, and displacement. Demographic data, number of visits to the emergency department, and documentation of IPV were also collected. Patients were stratified into four groups based on clinical chart review: confirmed IPV, possible IPV, not suspected for IPV, and not IPV. Historical imaging analysis for IPV prediction was also performed. RESULTS: There were 62 patients, with a mean age of 31 years (IPV: 12 confirmed, 8 possible, 8 suspected not IPV, 34 confirmed not IPV). Comparative analysis with and without suspected cases demonstrated IPV to be associated with nondisplaced fractures (95% versus 43%; P < .001 and 91% versus 44%; P = .012). Confirmed cases were also associated with homelessness (46% versus 0%; P < .001), and the number of documented emergency department visits (median 7.0; interquartile range 2.0-12.8 versus 1.0; interquartile range 1.0-2.0; P < .001). Formal documentation of IPV evaluation was completed in only 14 of 62 (22.5%) patients. Historical imaging analysis predicted IPV in 8 of 12 (75%) confirmed IPV cases. CONCLUSION: Up to one-third of adult women sustaining isolated ulnar fractures may be the victims of IPV. Lack of displacement on radiographs, frequent emergency department visits, and homelessness would favor IPV etiology.

Spinal Anesthesia Associated With Increased Length of Stay Compared to General Anesthesia for Ankle Open Reduction Internal Fixation: A Propensity-Matched Analysis.

General and spinal anesthesia are both utilized for patients undergoing open reduction internal fixation of the ankle, but there are little data comparing early complication rates. The purpose of this study was to compare duration of surgery, length of stay, and rates of postoperative adverse events within 30 days in patients undergoing open reduction internal fixation of ankle fracture using spinal versus general anesthesia. Adult patients who underwent open reduction internal fixation of a closed ankle fracture from 2012 to 2016 were retrospectively identified from American College of Surgeons National Surgical Quality Improvement Program. Duration of surgery, length of stay, 30-day adverse events, and unplanned readmissions were compared between patients who received general anesthesia and spinal anesthesia. Propensity adjustment with respect to known risk factors for complications and adjunctive regional block was used to match patients. Of the 10,795 patients included after applying the inclusion and exclusion criteria, 9862 (91.36%) received general anesthesia and 933 (8.64%) received spinal anesthesia. Using propensity-scored matching, 841 patients in the spinal cohort were matched to 3364 patients in the general cohort. Spinal anesthesia was associated with increased length of stay (+0.5 days, 95% confidence interval 0.23-0.77, p < .001). There were no differences in the rates of major/minor complications, mortality, transfusions, unplanned readmissions, or duration of surgery. General anesthesia is predominantly used for fixation of ankle fractures. While spinal anesthesia is associated with lower complication rates in hip and knee surgery, we found that it is associated with increased length of stay in patients undergoing open reduction internal fixation of the ankle within 30 days of surgery.

Elective lumbar fusion in the United States: national trends in inpatient complications and cost from 2002-2014.

BACKGROUND: Elective fusions for degenerative spine disease have increased over the past two decades in the USA, with variability in complications and hospital costs. The additional service costs associated with adverse perioperative events remain unknown. Our objective is to improve understanding of trends in safety and cost of elective lumbar fusions on a national scale. METHODS: A weighted sample of 1,526,386 adults undergoing elective lumbar fusion for degenerative indications were identified in the National Inpatient Sample (NIS) years 2002-2014. Twelve categories of major complications by system, and patient/hospital variables, were evaluated as predictors of the overall reimbursed cost. Mean differences (B) and 95% confidence intervals [95% CI] are reported. Significance is assessed at P<0.001. RESULTS: Nineteen percent of patients experienced inpatient complication. After adjusting for inflation, the mean overall cost was $ 32,802±19,557. Costs increased with presence of each of the 12 categories of complications, and by number of levels fused. Rates of most frequent complications and their adjusted cost-of-care were acute postoperative anemia (11.2%, B=$ 1817 [$ 1722-1913], P<0.001), renal/urinary (1.9%, B=$ 510 [$ 288-732], P<0.001), pulmonary (1.8%, B=$ 6014 [$ 5785-6243], P<0.001) and gastrointestinal (1.8%, B=$ 3699 [$ 3490-3908, P<0.001). The costliest adverse events were infection (B=$ 15,882 [$ 15,424-16,339], P<0.001), thromboembolism (B=$ 8856 [$ 8400-9311], P<0.001), hematoma/seroma/vascular (B=$ 8050 [$ 7784-8316], P<0.001). CONCLUSIONS: The number of elective lumbar fusions for degenerative spine disease increased 276% in the USA from 2002-2014 with growing surgeon preference for lateral techniques, and an increasing proportion of combined anterior and posterior approaches. Overall complication rates decreased from 2002-2014, despite an older patient population. After adjusting for inflation, cost was relatively stable across years 2002-2014. Complications by system were associated with increased cost, underscoring the need to address sources of complications and optimize early postoperative recovery in order to reduce healthcare expenditure.