Implementation of a Multidisciplinary Preoperative Protocol for Geriatric Hip Fractures Improves Time to Surgery at a Level III Trauma Center.

Introduction: Hip fractures are common among the elderly, and delays in time to surgery (TTS) and length of stay (LOS) are known to increase mortality risk in these patients. Preoperative multidisciplinary protocols for hip fracture management are effective at larger trauma hospitals. The purpose of this study is to evaluate the effect of a similar multidisciplinary preoperative protocol for geriatric hip fracture patients at our Level III trauma center. Materials and Methods: In this single-center retrospective study, patients aged 65 and older who were admitted from March 2016 to December 2018 (pre-protocol group, Cohort #1, n = 247) and from August 2021 to September 2022 (post-protocol group, Cohort #2, n = 169) were included. Demographic information, TTS, and LOS were obtained and compared using Student's t-test and Chi-square testing. Results: There was a significant decrease in TTS in Cohort #2 compared to Cohort #1 (P < .001). There was a significant increase in LOS in Cohort #2 compared to Cohort #1 (P < .05), but when comparing a subset of Cohort #2 (Subgroup 2B, patients admitted from May to September 2022 when the effects of COVID-19 were likely dissipated) to Cohort #1, there was no significant difference in LOS (P = .13). For patients admitted to skilled nursing facilities (SNF), LOS in Cohort #2 was significantly longer than in Cohort #1 (P = .001). Discussion: In general, Level III hospitals have fewer perioperative resources compared to larger Level I hospitals. Despite this fact, this multidisciplinary preoperative protocol effectively reduced TTS which improves mortality risk in elderly patients. LOS is a multifactorial variable, and we believe the COVID-19 pandemic was a significant confounder that reduced available SNF beds in our area which prolonged the average LOS in Cohort #2. Conclusion: A multidisciplinary preoperative protocol for geriatric hip fracture management can improve efficiency of getting patients to surgery at Level III trauma centers.

The COVID-19 pandemic and follow-up for shoulder surgery: The impact of a shift toward telemedicine on validated patient-reported outcomes.

INTRODUCTION: The emergence of COVID-19 and its ensuing restrictions on in-person healthcare has resulted in a sudden shift towards the utilization of telemedicine. The purpose of this study is to assess patient satisfaction and patient-reported outcome measures (PROMs) for individuals who underwent follow-up for shoulder surgery using telemedicine compared to those who received traditional in-person clinic follow-up. METHODS: Patients who underwent either rotator cuff repair or total shoulder arthroplasty during a designated pre-COVID-19 (traditional clinic follow-up) or peri-COVID-19 (telemedicine follow-up) span of time were identified. PROMs including the American Shoulder and Elbow Surgeons standardized assessment form, the three-level version of the EQ-5D form, the 12-Item Short Form survey, and a modified version of a published telemedicine survey were administered to participants six months post-operatively via phone call. RESULTS: Sixty patients agreed to participate. There was no significant difference between the pre-COVID-19 and peri-COVID-19 groups in patient satisfaction with their follow-up visit (p = 0.289), nor was there a significant difference in PROMs between the two groups. In total, 83.33% of the telemedicine group and 70.37% of the in-person clinic group preferred traditional in-person follow-up over telemedicine. DISCUSSION: In a cohort of patients who underwent telemedicine follow-up for shoulder surgery during the COVID-19 pandemic, there was no difference in patient satisfaction and PROMs compared to traditional in-person clinic follow-up. This study indicates that while the majority of participants preferred face-to-face visits, patients were relatively satisfied with their care and had similar functional outcome scores in both groups, despite the large disruption in healthcare logistics caused by COVID-19.

Evaluation of a Novel Multidisciplinary Preoperative Workup Strategy for Geriatric Hip Fractures.

OBJECTIVE: To determine the financial and clinical impact of a standardized, multidisciplinary team for surgical clearance and optimization in geriatric hip fracture patients. DESIGN: Retrospective case series. SETTING: Level-1 trauma center. PATIENTS: One hundred twenty-four geriatric patients (age >65 years old) in the preprotocol group (cohort 1; January 2017-December 2018) and 98 geriatric patients in the postprotocol group (cohort 2; October 2019-January 2021) with operative hip fractures. INTERVENTION: Implementation of a multidisciplinary team protocol consisting of Anesthesiology, Internal Medicine and Orthopedic Surgery departments for the assessment of medical readiness and optimization for surgical intervention in geriatric hip fractures. MAIN OUTCOME MEASURES: Rate of cardiology consultation, need for cardiac workup (echocardiography stress testing, heath catheterization), time to medical readiness (TTMR), time to surgery, case-cancellation rate, length of stay (LOS), and total hospitalization charges. RESULTS: Following implementation of the new protocol, there were significant ( P < 0.001) decreases in TTMR (19 vs. 11 hours), LOS (149 vs. 120 hours), case cancellation rate, and total hospital charges ($84,000 vs. $62,000). There were no significant differences with respect to in-hospital complications or readmission rates/mortality rates at 1 year. CONCLUSIONS: Following implementation of a protocolized, multidisciplinary approach to optimizing geriatric fracture patients, we were able to demonstrate a reduction in unnecessary preoperative testing, TTMR for surgery, case cancellation rate, LOS, and total hospitalization charge-without a concomitant increase in complications or mortality. This study highlights that standardization of the perioperative care for geriatric hip fracture patients can provide effective patient care while also lowering financial and logistical burden in care for these injuries. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical and Biomechanical Effects of Femoral Neck Buttress Plate used for Vertical Femoral Neck Fractures.

PURPOSE: To investigate both the biomechanical and clinical effect of an inferomedial femoral neck buttress plate (FNBP) used to augment a sliding hip screw (SHS) and anti-rotational screw (ARS) in the treatment of traumatic vertical femoral neck fractures. METHODS: Part 1: Clinical - Retrospective review of patients under age 65 treated with open reduction of a vertical femoral neck fracture. Patients were divided into two groups: Group 1 patients (18 patients) had SHS/ARS fixation augmented with a FNBP, while Group 2 patients (18 patients) had SHS/ARS fixation alone and were matched for age and sex. Demographic data, OTA fracture classification, immediate post-operative and follow-up radiographs were analyzed for quality of reduction, femoral neck shortening (FNS), neck-shaft angle (NSA), avascular necrosis (AVN) and union. Part 2: Biomechanical - Pauwels III femoral neck osteotomy was created in five pairs of cadaveric specimens, then each fracture was reduced and stabilized with a SHS/ARS construct. Specimens were matched and split into Groups 1 and 2, similar to Part 1. Cadaveric specimens were axially loaded in cyclical fashion to analyze for construct stiffness, fracture displacement femoral neck shortening and changes in the neck shaft angle. RESULTS: Part 1: There were 18 matched patients (14 males and 4 females) in both Group 1 and Group 2. There were no statistically significant differences between the two groups with respect to Pauwels angle, femoral neck shortening, changes in neck-shaft angle, AVN or nonunion. One reoperation in Group 1 and four in Group 2. Part 2: All five cadaveric specimens in both groups survived the 10,000-cycle loading regimen. We were unable to detect any significant differences between the two groups with respect to construct stiffness, change in neck-shaft angle or amount of femoral neck shortening. CONCLUSION: Based on the results of both clinical case series and biomechanical testing, an inferomedial neck buttress plate does not appear to offer long-term benefits with respect to maintenance of alignment or achieving union but may potentially help in obtaining the reduction.

Relationship Between Age at Adult Height and Knee Mechanics During a Drop Vertical Jump in Men.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are relatively common among younger athletes, with significant physical, psychological, and financial consequences. Research has largely focused on female athletes by identifying specific risk factors for an ACL injury, including variation in pubertal growth timing. There is less known about risk factors in males, and little is known about the effects of pubertal development on ACL injury risk in men. PURPOSE/HYPOTHESIS: The purpose of this study was to analyze the relationship between an indicator of pubertal growth timing (age at adult height) and biomechanical risk for ACL injuries in men. We hypothesized that earlier age at adult height is correlated with riskier landing biomechanics during a drop vertical jump (DVJ) in men. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 21 recreationally active male students (age range, 20-33 years) were included. Participants completed a questionnaire on age at adult height and limb dominance, and anthropometric measurements were taken. There were 6 DVJ tests performed, with participants landing on a force plate while digital cameras recorded kinematic data from retroreflective markers placed according to the Helen Hayes marker system. Primary outcomes were sagittal and frontal plane knee kinematics and kinetics during contact. Data were analyzed using Pearson product-moment correlation. RESULTS: In both limbs, age at achieving adult height was significantly negatively correlated with knee flexion/extension angle at toe-off (dominant: r = -0.79, P < .01; nondominant: r = -0.74, P < .01) and with peak flexion (dominant: r = -0.63, P < .01; nondominant: r = -0.70, P < .01) and extension (dominant: r = -0.66, P < .01; nondominant: r = -0.56, P = .01) angles during contact. In the nondominant limb, age at adult height was significantly negatively correlated with varus/valgus angle at initial contact (r = -0.43; P = .05) and toe-off (r = -0.44; P = .04) and was positively correlated with peak varus moment during contact (r = 0.42; P = .06). Age at adult height was also positively correlated with peak vertical ground-reaction force (r = 0.58; P < .01). CONCLUSION: Later age at adult height was correlated with riskier landing profiles in this study. This suggests that males with later or longer pubertal growth may have increased mechanical risk for ACL injuries. A better understanding of the effects of pubertal growth on landing biomechanics can improve the early identification of male athletes at greater risk for injuries.

A Qualitative Study Assessing Information on the Internet Compared With AAOS Guidelines for the Treatment of Distal Radius Fractures.

The goal of this study was to compare information available on the Internet about the treatment of distal radius fractures with the guidelines established by the American Academy of Orthopaedic Surgeons (AAOS) in a qualitative observational study. A scoring system was used to compare the top 20 websites, excluding advertisements, from Google, Bing, and Yahoo with the AAOS guidelines. In addition, the results of the advertising content and the social media content were discussed. Of the 32 unique websites included in the study, 22 (68.75%) suggested operative fixation for fractures with unacceptable postreduction alignment (radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement or step-off >2 mm) as opposed to cast fixation. Of the 32 sites, 26 (81.25%) were unable to recommend for or against any 1 specific operative method for fixation of distal radius fractures. Only 2 of 32 (6.25%) sites mentioned age-specific recommendations, and 6 of 32 (18.75%) mentioned accurate activity protocols. Because the AAOS cannot recommend for or against immobilization of the elbow in patients treated with cast immobilization, it is reasonable that 7 of 32 (21.88%) sites discussed these options. The websites common to all 3 search engines also scored very well, with 84.89% of their recommendations being consistent with the AAOS recommendations. Most websites contain appropriate recommendations for the treatment of distal radius fractures. However, there is a significant amount of misinformation as well. The available information may be difficult for patients to interpret and may affect their expectations about care. [Orthopedics. 2020;43(2):e79-e86.].

Core Decompression with Synthetic Grafting as a Joint Preservation Strategy in Humeral Avascular Necrosis Due to Sickle Cell Anemia: A Case Report.

INTRODUCTION: Avascular necrosis (AVN) of the femoral or humeral heads in patients with sickle cell anemia is a common and painful condition. There is currently no gold standard treatment protocol for this condition. Typically, the pain is managed with narcotics and activity restriction until there has been collapse of the subchondral bone with a degree of arthrosis sufficient to warrant total joint arthroplasty. This method entails prolonged pain for the patient and decreases the ability to function occupationally and recreationally. CASE REPORT: A 51-year-old African-American woman with a history of sickle cell anemia presented for the evaluation of significant bilateral shoulder pain that was confirmed to be AVN via radiographs and magnetic resonance imaging of both her humeral heads without joint collapse. She tried and failed conservative management with physical therapy and optimization of sickle cell treatment with pain medications for years, so she desired surgical management. Arthroscopically assisted core decompression of her humeral heads with synthetic grafting was performed in an attempt at joint preservation. CONCLUSION: This report demonstrates a technique of staged decompression of necrotic bone in the bilateral humeral heads with synthetic bone grafting to determine if this could function as a joint preservation strategy. This procedure was considered successful to alleviate the patients' pain in both of her arms. The application of this procedure is significant because it could be used in various future medical joint preservation cases for a wide range of patients.

Drosophila Eye Model to Study Neuroprotective Role of CREB Binding Protein (CBP) in Alzheimer's Disease.

BACKGROUND: The progressive neurodegenerative disorder Alzheimer's disease (AD) manifests as loss of cognitive functions, and finally leads to death of the affected individual. AD may result from accumulation of amyloid plaques. These amyloid plaques comprising of amyloid-beta 42 (Aß42) polypeptides results from the improper cleavage of amyloid precursor protein (APP) in the brain. The Aß42 plaques have been shown to disrupt the normal cellular processes and thereby trigger abnormal signaling which results in the death of neurons. However, the molecular-genetic mechanism(s) responsible for Aß42 mediated neurodegeneration is yet to be fully understood. METHODOLOGY/PRINCIPAL FINDINGS: We have utilized Gal4/UAS system to develop a transgenic fruit fly model for Aß42 mediated neurodegeneration. Targeted misexpression of human Aß42 in the differentiating photoreceptor neurons of the developing eye of transgenic fly triggers neurodegeneration. This progressive neurodegenerative phenotype resembles Alzheimer's like neuropathology. We identified a histone acetylase, CREB Binding Protein (CBP), as a genetic modifier of Aß42 mediated neurodegeneration. Targeted misexpression of CBP along with Aß42 in the differentiating retina can significantly rescue neurodegeneration. We found that gain-of-function of CBP rescues Aß42 mediated neurodegeneration by blocking cell death. Misexpression of Aß42 affects the targeting of axons from retina to the brain but misexpression of full length CBP along with Aß42 can restore this defect. The CBP protein has multiple domains and is known to interact with many different proteins. Our structure function analysis using truncated constructs lacking one or more domains of CBP protein, in transgenic flies revealed that Bromo, HAT and polyglutamine (BHQ) domains together are required for the neuroprotective function of CBP. This BHQ domain of CBP has not been attributed to promote survival in any other neurodegenerative disorders. CONCLUSIONS/SIGNIFICANCE: We have identified CBP as a genetic modifier of Aß42 mediated neurodegeneration. Furthermore, we have identified BHQ domain of CBP is responsible for its neuroprotective function. These studies may have significant bearing on our understanding of genetic basis of AD.

Novel neuroprotective function of apical-basal polarity gene crumbs in amyloid beta 42 (aß42) mediated neurodegeneration.

Alzheimer's disease (AD, OMIM: 104300), a progressive neurodegenerative disorder with no cure to date, is caused by the generation of amyloid-beta-42 (Aß42) aggregates that trigger neuronal cell death by unknown mechanism(s). We have developed a transgenic Drosophila eye model where misexpression of human Aß42 results in AD-like neuropathology in the neural retina. We have identified an apical-basal polarity gene crumbs (crb) as a genetic modifier of Aß42-mediated-neuropathology. Misexpression of Aß42 caused upregulation of Crb expression, whereas downregulation of Crb either by RNAi or null allele approach rescued the Aß42-mediated-neurodegeneration. Co-expression of full length Crb with Aß42 increased severity of Aß42-mediated-neurodegeneration, due to three fold induction of cell death in comparison to the wild type. Higher Crb levels affect axonal targeting from the retina to the brain. The structure function analysis identified intracellular domain of Crb to be required for Aß42-mediated-neurodegeneration. We demonstrate a novel neuroprotective role of Crb in Aß42-mediated-neurodegeneration.

Intraoperative floppy iris syndrome associated with alpha1-adrenergic receptor antagonists.

OBJECTIVE: To describe intraoperative floppy iris syndrome (IFIS) in association with alpha(1)-adrenergic receptor (alpha(1)AR) antagonists by conducting a thorough literature review. DATA SOURCES: Literature retrieval was accomplished by searching MEDLINE (2000-December 2007) using the terms intraoperative floppy iris syndrome (IFIS), adrenergic alpha-antagonist(s), tamsulosin, doxazosin, terazosin, and/or alfuzosin. In addition, reference lists from identified publications were reviewed to identify additional reports and studies of interest. STUDY SELECTION AND DATA EXTRACTION: All articles in English identified from data sources were reviewed for relevance and uniqueness prior to inclusion. DATA SYNTHESIS: IFIS was first described in 2005 as a clinical triad observed during cataract surgery that includes fluttering and billowing of the iris stroma, propensity for iris prolapse, and constriction of the pupil. IFIS increases the risk of complications during cataract surgery. Numerous reports have linked IFIS to use of alpha(1)AR antagonists, most notably tamsulosin, which is prescribed for benign prostatic hyperplasia. Tamsulosin blocks prostatic alpha(1A)ARs but may also selectively block alpha(1A)ARs in the iris dilator muscle, preventing mydriasis during cataract surgery. Other alpha(1)AR antagonists, including terazosin, doxazosin, and alfuzosin, have also been linked to IFIS; however, their relationship to the syndrome is not as definitive. When ophthalmologists are aware of a patient's previous alpha(1)AR antagonist exposure, specific steps can be taken to reduce the risk of surgical complications. Corrective measures used during surgery have included iris expansion hooks, intracameral phenylephrine, and preoperative atropine. CONCLUSIONS: IFIS is a clinical syndrome observed during cataract surgery reported in patients taking systemic alpha(1)AR antagonists. It has been most strongly linked to use of tamsulosin. Medication washout periods of up to 2 weeks and specific surgical procedures have been attempted to reduce risk of complications from alpha(1)AR antagonists in the setting of cataract surgery. Patients should be educated regarding potential risks of this drug class so that they can discuss them with their healthcare providers, specifically ophthalmologists, prior to cataract surgery.

Vitreous injections of pegaptanib sodium triggering allergic reactions.

PURPOSE: To report two cases of systemic allergic response associated with vitreous administration of pegaptanib sodium. DESIGN: Observational case report. METHODS: Two patients were treated for systemic allergic reactions associated with the administration of pegaptanib sodium. RESULTS: One patient developed a delayed and prolonged anaphylactoid reaction following administration of his first dose of intraocular pegaptanib sodium. The second patient received four injections of pegaptanib over the course of six months. He developed mild lip swelling and prolonged urticarial rash following the first injection, which subsided when pegaptanib was suspended. CONCLUSIONS: Severe hypersensitivity reactions may occur in association with vitreous administration of pegaptanib sodium and may be associated with prolonged urticaria and angioedema. Elderly individuals with comorbidities are at higher risk for fatality from severe hypersensitivity reactions in the ambulatory setting. Physicians administering pegaptanib sodium should review emergency response and airway procedures.