Fractional Lengthening of Forearm Flexor Tendons: A Cadaveric Biomechanical Analysis.

PURPOSE: Multiple procedures have been described for wrist and finger flexion contractures and spasticity. Fractional lengthening of forearm flexor tendons involves making parallel transverse tenotomies at the musculotendinous junction to elongate the muscle. Currently, there is limited literature to define the biomechanical consequences of this lengthening technique. METHODS: Forty-eight flexor tendons were harvested from eight paired upper limbs including flexor carpi radialis, flexor carpi ulnaris, flexor pollicis longus, and flexor digitorum superficialis tendons. Each tendon that was lengthened was paired with the contralateral tendon as a control. A pair of transverse tenotomies were completed for the fractional lengthening. The first tenotomy was performed at the musculotendinous junction where the tendon narrowed to 75% of its maximal width. The second tenotomy was made 1 cm distal to the first. Tendon length was measured before and after fractional lengthening at a constant resting tension of 1 N. The maximum load at failure of each tendon and the mechanism of failure were each measured and compared with the contralateral side. RESULTS: After fractional lengthening, the mean increase in resting tendon length was 4 mm. When loaded to failure, the mean maximum load of fractionally lengthened tendons was 42% of the mean maximum load of intact tendons. All lengthened tendons failed at the distal tenotomy site. CONCLUSIONS: Fractional lengthening resulted in an increase of 3-6 mm (mean: 4 mm) in tendon length at resting tension. There was a significant loss in tensile strength and load to failure following fractional lengthening compared with an intact musculotendinous unit. CLINICAL RELEVANCE: The reduction in tensile strength following fractional lengthening results in loads at failure that are, in some cases, lower than the estimated forces required to perform basic tasks. Caution during the healing and rehabilitation period is warranted.

Biomechanical Analysis of Headless Compression Screw Versus Tension Band Wiring for Proximal Interphalangeal Joint Arthrodesis.

PURPOSE: Proximal interphalangeal (PIP) joint arthrodesis is a procedure employed to address arthritis, instability, and deformity. Multiple fixation methods are available to maintain stability across the arthrodesis interval, including headless compression screws (HCSs), tension band wiring (TBW), plating, and Kirschner wire constructs. The purpose of this study was to compare the biomechanical properties of the HCS and TBW techniques. METHODS: Thirty-two nonthumb digits from the paired upper limbs of four fresh frozen cadavers were divided into pairs, matching contralateral digits from the same specimen. One PIP joint of each pair was fused with an antegrade 3.5 mm HCS, and the second was fused with TBW using 0.035 in. Kirschner wires with 24-gauge dental wire. Each construct was then stressed to 10 N in the radial deviation, ulnar deviation, flexion, and extension planes, and stiffness (N/mm) was calculated. The fingers were stressed to failure in extension with the ultimate load and mode of failure recorded. RESULTS: When stressed in extension, the HCS construct had a significantly greater mean stiffness than the TBW construct (16.4 N/mm vs 10.8 N/mm). The stiffness in all other planes of motion were similar between the two constructs. The mean ultimate load to failure in extension was 91.4 N for the HCS and 41.9 N for the TBW. The most common mode of failure was fracture of the dorsal lip of the proximal phalanx (13/16) for the HCS and bending of the K-wires (15/16) for TBW. CONCLUSIONS: Arthrodesis of the PIP joint using a HCS resulted in a construct that was significantly stiffer in extension with greater than double the load to failure compared to TBW. CLINICAL RELEVANCE: Although the stiffness required to achieve successful PIP joint arthrodesis has not been well quantified, the HCS proved to be the most favorable construct with respect to initial strength and stability.

30-Day Postoperative Complications After Surgical Treatment of Proximal Humerus Fractures: Reverse Total Shoulder Arthroplasty Versus Hemiarthroplasty.

INTRODUCTION: The purpose of this study was to evaluate risk factors associated with complications after reverse total shoulder arthroplasty (TSA) and hemiarthroplasty for the treatment of proximal humerus fractures. METHODS: A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database was conducted. Current Procedural Terminology codes were used to identify patients treated for proximal humerus fracture with reverse TSA or hemiarthroplasty between 2005 and 2018. RESULTS: One thousand five hundred sixty-three shoulder arthroplasties were conducted: 436 hemiarthroplasties and 1,127 reverse TSA. The overall complication rate was 15.4% (15.7% reverse TSA; 14.7% hemiarthroplasty) (P = 0.636). Most frequent complications included transfusion 11.1%, unplanned readmission 3.8%, and revision surgery 2.1%. A 1.1% incidence of thromboembolic events was noted. Complications occurred most frequently in patients older than 65 years; male; and patients with anemia, American Society of Anesthesiologists classification III-IV, inpatient procedure, bleeding disorders, duration of surgery >106 minutes, and length of stay >2.5 days. Patients with body mass index >36 kg/m2 had a decreased risk of 30-day postoperative complications. DISCUSSION: There was a 15.4% complication rate in the early postoperative period. In addition, no notable difference was found in complication rates between groups (hemiarthroplasty: 14.7%; reverse TSA 15.7%). Future studies are needed to determine whether there is a difference between these groups in the long-term outcome and survivorship of these implants.

Evaluation of Radiographic Parameters Following Dorsal Wrist-Spanning Plate Fixation of Distal Radius Fractures to the Second Versus Third Metacarpal.

PURPOSE: Dorsal wrist-spanning plate fixation for comminuted, intra-articular distal radius fractures involves the indirect reduction of intra-articular fractures via ligamentotaxis. The reduction is maintained by application of a bridge plate from the radial diaphysis to either the second or third metacarpal. The objective of this study was to retrospectively compare radiographic outcomes between distal radius fractures managed with bridge plate fixation to the second versus third metacarpal. METHODS: A single-institution retrospective review identified 50 cases of distal radius fractures that underwent dorsal wrist-spanning plate fixation, with 9 and 41 fractures undergoing fixation to the second and third metacarpals, respectively. Radiographic parameters, such as radial height, radial inclination, volar tilt, and ulnar variance, were measured at 3 time points: immediately after surgery, immediately prior to elective plate removal, and at the final follow-up. Radiographic measurements of the 2 cohorts were compared at the 3 time points. RESULTS: Final radiographs showed an average radial height of 8.9 mm versus 9.4 mm for the second versus third metacarpal cohorts, respectively; average radial inclination of 17.4° for both the second and third metacarpal cohorts; average volar tilt of 1.9° versus 1.7° for the second versus third metacarpal cohorts, respectively; and an average ulnar variance of +0.6 mm versus +0.1 mm for the second versus third metacarpal cohorts, respectively. Radiographic parameters of the second and third metacarpal cohorts were similar across all the time points. Additionally, evaluation of the radiographic parameters across the 3 time points (immediately after surgery, immediately prior to elective plate removal, and at the final follow-up) demonstrated little to no loss of radiographic alignment. CONCLUSIONS: Radiographic outcomes for distal radius fractures managed with bridge plate fixation to the second versus third metacarpal appear similar. The distal plate fixation site can likely be determined on the basis of fracture anatomy and patient-specific features. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Amputation and infection are the greatest fears in patients with diabetes foot complications.

AIMS: To determine the degree patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations fear complications (death, dialysis, heart attack, stroke, blindness, diabetic foot infection, minor and major lower extremity amputation [LEA]) that can occur and to assess if there is a difference between fears of patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations and diabetic patients without these complications. METHODS: 478 patients completed an eight question Likert scale survey. The study group was defined as non-infected foot ulcers, neuropathic fractures and Charcot neuroarthropathy. RESULTS: Of the 478 patients, 121 (25.3 %) had diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations and 357 (74.7 %) did not. The study group had significantly higher odds of reporting extreme fear of foot infection (OR 2.8, 95 % CI 1.8-4.5), major LEA (OR 2.8, 95 % CI 1.8-4.4), minor LEA (OR 2.3, 95 % CI 1.5-3.5), blindness (OR 2.0, 95 % CI 1.3-3.2), dialysis (OR 2.0, 95 % CI 1.1-3.3), and death (OR 2.4, 95 % CI 1.4-4.2). In the study group highest rated fear measures were foot infection (3.71, SD 1.23), minor amputation (3.67, SD 1.45) and major amputation (3.63, SD 1.52). There were no significant differences in the mean fear of infection, minor amputation or major amputation. CONCLUSION: Patients with diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations reported higher fear ratings of diabetes-related complications compared to those without these complications.

Biomechanical Comparison of 4 Transsacral Fixation Constructs in a Type 61C, Zone II Pelvic Fracture Model.

OBJECTIVES: OTA/AO 61C pelvic ring injuries are vertically unstable because of complete sacral fractures combined with anterior ring injury. The objective of this study was to compare the biomechanical characteristics of 4 transsacral screw constructs for posterior pelvic ring fixation, including one that uses a novel fixation method with a pair of locked washers with interdigitating cams. METHODS: Type C pelvic ring disruptions were created on 16 synthetic pelvis models. Each pelvis was fixated with an S2 screw in addition to being allocated to 1 of 4 transsacral constructs through S1: (1) 8.0-mm screw, (2) 8.0-mm bolt, (3) 8.0-mm screw locked with a nut, and (4) 8.00-mm screw locked with a nut with the addition of interdigitating washers between the screw head and ilium on the near cortex, and ilium and nut on the far cortex. The anterior ring fractures were not stabilized. Each pelvis underwent 100,000 cycles at 250 N and was then loaded to failure using a unilateral stance testing model. The anterior and posterior osteotomy sites were instrumented with pairs of infrared (IR) light-emitting markers, and the relative displacement of the markers was monitored using a three-dimensional (3D) motion capture system. Displacement measurements at 25,000; 50,000; 75,000; and 100,000 cycles and failure force were recorded for each pelvis. RESULTS: The novel washer design construct performed better than the screw construct with less posterior ring motion at 75,000 ( P = 0.029) and 100,000 cycles ( P = 0.029). CONCLUSIONS: The novel interdigitating washer design may be superior to using a screw construct alone to achieve rigid, locked posterior ring fixation in a synthetic pelvis model with a Type C pelvic ring disruption.

Risk Factors and Reasons for Emergency Department Visits Within 30 Days of Elective Hand Surgery: An Analysis of 3,261 Patients.

Background: The frequency of hand and elbow surgeries occurring in outpatient and elective settings is on the rise. Emergency department (ED) visits in the postoperative period are increasingly used as quality measures for surgical care. The aim of this study is to determine the number of postoperative ED visits, the primary reason for these visits, and to identify risk factors associated with these visits. Methods: We examined all elective hand and elbow procedures performed at two hospitals within a single healthcare network between 2008 and 2017. A total of 3,261 patients met the study criteria. Descriptive statistics were calculated for our population, followed by univariate and multivariate analyses, to identify risk and protective factors associated with ED visits in the first 30 days after surgery. Results: Eighty-seven of 3,261 patients presented to the ED within 30 days of their operation (2.7%). The most common reasons for ED visits were related to pain (28.7%), swelling (26.4%), and concerns for infection (20.7%). Univariate analysis indicated history of drug use, number of procedures, smoking history, and serum albumin <3.5 mg/dL as risk factors for returns to the ED. Multivariate analysis identified history of drug use, number of procedures, and serum albumin <3.5 mg/dL as independent risk factors. Smoking history failed to achieve statistical significance as an independent risk factor. Both univariate and multivariate analyses identified age >60 years as protective for postoperative ED visits. Conclusions: ED visits within the first 30 days after elective hand surgery are relatively common, despite remarkably low complication rates among these procedures. This information may help to improve risk stratification in these patients, and to aid in the development of enhanced postoperative follow-up strategies to reduce unnecessary utilization of emergency medical services. Level of Evidence: Level III (Therapeutic).

Are Readmission and Reoperation Rates for Lower Extremity Necrotizing Fasciitis Different Between Patients With and Without Diabetes Mellitus?

Necrotizing fasciitis is a condition associated with high morbidity and mortality unless emergent surgery is performed. This study aims to understand the hospital course of diabetic and nondiabetic patients managed for lower-extremity necrotizing fasciitis by identifying factors contributing to readmissions and reoperations. About 562 patients treated for lower-extremity necrotizing fasciitis were selected from the American College of Surgeons-National Surgical Quality Improvement Program database between 2012 and 2017. The unplanned reoperation and readmission rates for all patients during the 30-day postoperative period were 9.4% and 5.3%, respectively. Out of 562 patients with lower-extremity necrotizing fasciitis, 326 (58.0%) patients had diabetes. Diabetes patients were more likely to undergo amputation (p < .00001). Neither readmission (6.1% vs 4.2%, p = .411) nor reoperation (8.6% vs 10.6%, p = .482) were significantly different between patients with and without diabetes. Neither readmission (7.2% vs 4.0%, p = .159) nor reoperation (4.1% vs 3.7%, p = .842) were significantly different between patients undergoing amputation and nonamputation procedures. In simple logistic regression, factors associated with unplanned reoperation included poorer renal function, thrombocytopenia, longer duration of surgery, longer hospital length of stay, postoperative surgical site infection, postoperative respiratory distress, and postoperative septic shock. Body mass index >30 kg/m2 was associated with decreased odds of readmission. In multiple logistic regression, surgical site infection was the only predictor of reoperation (adjusted odds ratio 7.32, 95% confidence interval 2.76-19.1), and any amputation was associated with readmission (adjusted odds ratio 4.53, 95% confidence interval 1.20-29.6). Further study is needed to understand patient characteristics to better direct management. However, the current study elucidates patient outcomes for a relatively rare condition.

Effect of Sensory Neuropathy on the Predictive Value of Inflammatory Biomarkers for Osteomyelitis in Diabetic and Nondiabetic Patients with Foot Infections.

OBJECTIVE: To investigate the predictive value of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in persons with and without diabetes with osteomyelitis (OM). METHODS: We evaluated 455 patients in a retrospective cohort study of patients admitted to the hospital with diabetic foot OM (n = 177), diabetic foot soft-tissue infections (STIs) (n = 176), nondiabetic OM (n = 51), and nondiabetic STIs (n = 51). Infection diagnosis was determined through bone culture, histopathologic examination for OM, and/or imaging (magnetic resonance imaging/single-photon emission computed tomography) for STI. The optimal cutoff values of ESR and CRP in predicting OM were determined by receiver operating characteristic curve analysis. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were determined through contingency tables. RESULTS: In persons without diabetes with STI or OM, the mean ESR and CRP differences were 10.0 mm/h and 2.6 mg/dL, respectively. In contrast, persons with diabetes had higher levels of each: 24.8 mm/h and 6.8 mg/dL, respectively. As a result, ESR and CRP predicted OM better in patients with diabetes. However, when patients were stratified by neuropathy status, ESR remained predictive of OM in diabetic patients with neuropathy (75% sensitivity, 58% specificity) but not in diabetic patients without neuropathy (50% sensitivity, 44% specificity). Also, CRP remained predictive irrespective of neuropathy status. A similar trend was observed in patients without diabetes. CONCLUSIONS: Previous studies have reported that ESR and CRP are predictive of OM. However, this study suggests that neuropathy influences the predictive value of inflammatory biomarkers. The underlying mechanisms require further study.

Effect of Smoking on Short-term Postoperative Complications After Elective Upper Extremity Surgery.

Background: There is a paucity of literature exploring the impact of smoking on short-term complications, readmissions, and reoperations after elective upper extremity surgery using a large multicenter national database. We hypothesized that smokers will have an increased rate of complications, readmissions, and reoperations compared with a cohort of nonsmokers undergoing elective upper extremity surgery. Methods: Patient data were collected from the American College of Surgeons National Surgical Quality Improvement Program database between the years 2012 and 2017. Patients were included if they underwent elective surgery of the upper extremity using 338 predetermined Current Procedural Terminology codes. The data collected were divided into patient demographics, comorbidities, perioperative variables, and 30-day complications. Current smoking status was defined as smoking within 1 year prior to surgery. The incidence of surgical complications, reoperations, and readmissions was compared between the 2 cohorts using multivariable regression analysis. Results: Of the 107 943 patients undergoing elective surgeries of the upper extremity, 73 806 met the inclusion criteria. Of these, 57 986 (78.6%) were nonsmokers in the year prior to surgery, and 15 820 (21.4%) were current smokers. Between these groups, current smokers were younger (P < .001), more often men (P < .001), had lower body mass index (P < .001), and more often underwent procedures that involved bone manipulation (P < .001). Multivariate regression analysis defined current smoking as significantly associated with overall surgical site complications, superficial surgical site infections, deep surgical site infections, reoperation, and readmission. Conclusion: Current smoking was significantly associated with an increase in all surgical site complications, readmissions, and reoperations after elective upper extremity surgery. Surgeons should consider smoking a modifiable risk factor for postoperative complications and appropriately counsel patients on outcomes and complications given the elective nature of upper extremity surgery.

The Impact of Hospitalization for Diabetic Foot Infection on Health-Related Quality of Life: Utilizing PROMIS.

Diabetic foot infections (DFI) are an increasingly common cause of hospitalizations. Once hospitalized with DFI, many patients require some level of amputation, often undergoing multiple operations. With increasing importance on patient-centered metrics, self-reported health-related quality of life (HRQOL) tools have been developed. This prospective cohort study aimed assessed the impact of DFI on HRQOL. Two hundred twenty-four patients completed the 29-item Patient-Reported Outcome Measurement Information System (PROMIS) and 12-Item Short Form (SF-12) survey. Secondary outcomes using the Foot and Ankle Ability Measures survey were obtained and included in the analysis. The study group was comprised of hospitalized patients with DFIs (n = 120), and the control group was comprised of patients with diabetes who were evaluated for routine outpatient foot care (n = 104); diabetic foot screening, wound care, onychomycosis, and/or callosities. Using this cohort, a propensity score-matched sample of hospitalized patients with DFI (n = 35) and control group patients (n = 35) was created for comparative analysis. The 2-independent sample t test was used to test for group differences on each of the PROMIS subscale outcomes. Using PROMIS, we found that hospitalized patients with DFI reported significantly worse HRQOL in 6 of 7 subscales (physical function, anxiety, depression, fatigue, social role, pain intensity; p value range: .0001-.02) compared to outpatients with diabetes evaluated for routine foot care. There was no significant difference between the 2 groups on sleep disturbance (p = .22). Patients hospitalized for DFI report lower HRQOL compared to patients with diabetes receiving routine outpatient foot care.

Effect of Diabetes and Hemoglobin A1c on Complications Following Elective Hand Surgery.

Background: Limited research exists investigating the association between diabetes and glycemic control on complications following elective hand surgery. The goal of this research was to assess the incidence of complications within 30 days of elective hand surgery in a large population of diabetic patients compared to a population of non-diabetics. Furthermore, we sought to examine the relationship of glycemic control, as measured by HbA1c, and postoperative complications. Methods: We performed a retrospective review of electronic medical records at our institution of all patients who underwent elective hand, forearm, or elbow surgery from the dates of January 1st, 2008 to December 31st, 2017. Patients were categorized as diabetic or non-diabetic and most recent HbA1c was documented. Multivariable analysis was employed to compare the incidence of surgical complications within 30 days between the diabetics and non-diabetic populations, adjusting for baseline patient characteristics. Results: A total of 3,261 patients met the inclusion criteria. There were 646 (20%) diabetic patients and 2,615 (80%) non-diabetic patients. No difference was found in the overall rate of complications between the cohort of diabetic and non-diabetic patients. Additionally, statistical analysis found no difference in the complication rate between insulin and non-insulin controlled diabetics. Rates of complications were stratified based on HbA1c level and statistical analysis found no increased risk of complications with increased hemoglobin A1c value. Conclusions: In our present study we were not able to demonstrate any significant difference in the 30 day complication rates between and non-diabetics undergoing elective hand surgery. This study attempted to aid in risk stratification of diabetic patients by evaluating preoperative glycemic indices in the form of HbA1c.

Effects of pH and NaCl on hydrolysis and transpeptidation activities of a salt-tolerant γ-glutamyltranspeptidase from Bacillus amyloliquefaciens S0904.

Bacillus amyloliquefaciens S0904 was selected as a hyperproducer of a glutamine-hydrolyzing enzyme which was identified as a γ-glutamyltranspeptidase catalyzing both hydrolysis and transpeptidation of glutamyl substrates. The signal peptide-truncated recombinant enzyme (rBAGGT) showed two-fold enhanced specific activity for hydrolysis and optimum pH shift to pH 7 from pH 6 compared with the wild type. The hydrolysis activity of rBAGGT was tolerant against NaCl up to 2.5 M, whereas the transpeptidation activity decreased by NaCl. At pH 6, the addition of 1.5 M NaCl not only enhanced the hydrolysis activity but also inhibited the transpeptidation activity to be ignorable. By contrast, at pH 9 in the absence of NaCl, the alkaline pH-favored transpeptidation activity was 99% of the maximum with only 15% of the maximum hydrolysis activity. In conclusion, the hydrolysis and transpeptidation activities of the recombinant BAGGT is controllable by changing pH and whether or not to add NaCl. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s10068-021-00928-6.

Development of a quantitative prediction algorithm for target organ-specific similarity of human pluripotent stem cell-derived organoids and cells.

Human pluripotent stem cell (hPSC)-derived organoids and cells have similar characteristics to human organs and tissues. Thus, in vitro human organoids and cells serve as a superior alternative to conventional cell lines and animal models in drug development and regenerative medicine. For a simple and reproducible analysis of the quality of organoids and cells to compensate for the shortcomings of existing experimental validation studies, a quantitative evaluation method should be developed. Here, using the GTEx database, we construct a quantitative calculation system to assess similarity to the human organs. To evaluate our system, we generate hPSC-derived organoids and cells, and detected organ similarity. To facilitate the access of our system by researchers, we develop a web-based user interface presenting similarity to the appropriate organs as percentages. Thus, this program could provide valuable information for the generation of high-quality organoids and cells and a strategy to guide proper lineage-oriented differentiation.

Impedance Measurement System for Assessing the Barrier Integrity of Three-Dimensional Human Intestinal Organoids.

Human pluripotent stem cell (hPSC)-derived intestinal organoids (HIOs) hold unprecedented promise for basic biology and translational applications. However, developing a quantitative method to evaluate the epithelial cell membrane integrity of HIOs as an in vitro intestinal barrier model is a major challenge because of their complex three-dimensional (3D) structure. In this study, we developed an impedance system to measure the change in electrical resistance of 3D HIOs depending on the integrity of the intestinal epithelial cell membrane, which can reflect functionality and maturity. The expression of intestinal maturation- and tight junction-related markers was significantly higher in HIOs matured in vitro by treatment with IL-2 than in control HIOs. Analysis of gap junction size indicated that mature HIOs have greater integrity, with approximately 30% more compact gaps than immature HIOs. We designed a multi-microchannel system controlled by the inhalation pressure where the HIO is loaded, which enhances the stability and sensitivity of the impedance signal. We demonstrated the applicability of the impedance system by showing the difference in resistance between control and mature HIOs, reflecting the expression of tight junction proteins and their maturation status. We also validated the impedance system by monitoring its resistance in real time during junctional damage to HIOs induced by a digestive agent. In summary, we suggest a quantitative method to directly quantify the physiological changes in complex 3D organoid structures based on impedance spectroscopy, which can be applied to noninvasively monitor live cells and therefore enable their use in subsequent experiments.

Postoperative Outcomes in Diabetic Pediatric Orthopaedic Surgery Patients: A National Database Study.

BACKGROUND: Although the negative effects of diabetes mellitus (DM) on operative outcomes in orthopaedic surgery is a well-studied topic in adults, little is known about the impact of this disease in children undergoing orthopaedic procedures. This study aims to describe the postoperative complications in pediatric orthopaedic surgery patients with DM. METHODS: Pediatric patients with insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) were retrospectively identified while selecting for elective orthopaedic surgery cases from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-Pediatric) database from 2012 to 2015. Univariate and multivariate analyses were performed to describe and assess outcomes when compared with nondiabetic patients undergoing similar procedures. RESULTS: Of the 17,647 patients identified, 105 (0.60%) had DM. Of those 105 patients, 68 had IDDM and 37 had NIDDM. The median age of DM patients was 13.8 years (11.9 to 15.5 y) and 37.1% of all DM patients were male. Comparing DM to non-DM patients, no significant differences were noted in the overall complications (1.4% vs. 1.9%, P>0.05) or reoperation rates (1.2% vs. 1.9%, P>0.05); however, DM patients did have a higher occurrence of unplanned readmissions (4.8% vs. 1.7%; P=0.037). Diabetic patients were statistically more likely to have an unplanned readmission with 30 days (adjusted odds ratio=3.34; 95% confidence interval=1.21-9.24, P=0.021). when comparing IDDM to NIDDM, there was no significant difference in outcomes. Comparing NIDDM to non-DM patients, there was an increased incidence of nerve injury (5.6% vs. 0.18%; P=0.023), readmission rate (11.1% vs. 1.8%; P=0.043), and reoperation rate (11.1% vs. 1%; P=0.013) in nonspinal procedures and an increased incidence of pulmonary embolism (10% vs. 0%; P=0.002) in spinal arthrodesis procedures. NIDDM predicted longer hospital stays (adjusted odds ratio=1.49; 95% confidence interval=1.04, 2.14; P=0.028) compared with nondiabetic patients in extremity deformity procedures. CONCLUSIONS: The 30-day complication, reoperation, and readmission rates for NIDDM patients were higher than that of non-DM patients. Furthermore, NIDDM is a predictor of longer hospital stays while DM is a predictor of unplanned readmissions. No statistical differences were noted when comparing outcomes of NIDDM to IDDM patients. LEVEL OF EVIDENCE: Level III.

Insulin Dependence Increases the Risk of 30-Day Postoperative Complications Following Ankle Fracture Surgery in Patients With Diabetes Mellitus.

Patients with diabetes mellitus that undergo ankle fracture surgery have higher rates of postoperative complications compared to patients without diabetes mellitus. We evaluated the rate of complications in insulin-dependent diabetes mellitus patients, non-insulin-dependent diabetes mellitus patients, and patients without diabetes in the 30-day postoperative period following ankle fracture surgery. We also analyzed hospital length of stay, unplanned readmission, unplanned reoperation, and death. Patients who underwent operative management for ankle fractures between 2012 and 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program® database using Current Procedural Terminology codes. Multiple logistic regression was implemented. Adjusted odds ratios were calculated along with the 95% confidence interval. A total of 19,547 patients undergoing ankle surgery were identified from 2012 to 2016. Of these patients, 989 (5.06%) had insulin-dependent diabetes mellitus, 1256 (6.43%) had noninsulin-dependent diabetes mellitus, and 17,302 (88.51%) did not have diabetes mellitus. Compared to patients without diabetes, patients with insulin-dependent diabetes mellitus had significantly greater adjusted odds of superficial surgical site infections, deep surgical site infections, osteomyelitis, wound dehiscence, pneumonia, unplanned intubation, mechanical ventilation, urinary tract infection, cardiac arrest, bleeding requiring transfusion, sepsis, hospital length of stay, unplanned readmission, unplanned reoperation, and death following ankle fracture surgery. We demonstrate that insulin-dependent diabetes mellitus is a strong predictor of 30-day postoperative complications, unplanned readmission, unplanned reoperation, and death following ankle fracture surgery.

Multifunctional Additives for High-Energy-Density Lithium-Ion Batteries: Improved Conductive Additive/Binder Networks and Enhanced Electrochemical Properties.

Cylindrical-type cells have been widely adopted by major battery and electric vehicle manufacturers owing to their price competitiveness, safety, and easy expandability. However, placement of electrodes at the core of cylindrical cells is currently restricted because of high electrode curvature and the lack of specialized electrodes and electrode materials. Here, we report the realization of highly flexible high-energy-density electrodes (active material loading of >98.4%) that can be used at the cores of cylindrical cells. The improved properties result from the introduction of a multifunctional poly(melamine-co-formaldehyde) (MF copolymer) additive, which yields a relatively more fluidic and well-dispersed slurry using only 0.08 wt %. MF copolymer-mediated formation of completely wrapped CNT/PVDF networks on LiCoO2 (LCO) and accompanying contact enhancement between LCO and carbon nanotubes (CNTs) resulted in an increase of electrical and mechanical properties of the two types (composites with or without collectors) of electrodes compared with those of additive-free electrodes. Flexibility tests were carried out by rolling electrodes onto cylinder substrates (diameters of ca. 1 and 10 mm); this process resulted in relatively lower resistance changes of the MF copolymer-containing electrodes than for the reference electrodes. In addition, capacity retention after 100 cycles for cells with and without MF copolymers was approximately 10-20% better for the samples with the MF copolymer than for those without. CNT/PVDF networks with MF copolymers were proven to induce a relatively thin and stable cathode electrolyte interface layer accompanying the chemical bond formation during cycling.

Early Outcomes After Surgical Management of Geriatric Patella Fractures.

OBJECTIVES: To report the incidence and risk factors for prolonged hospitalization, discharge to a facility, and postoperative complications in geriatric patients who underwent surgery for patella fracture. DESIGN: Retrospective database review. SETTING: The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) collects data from 600 hospitals across the United States. PATIENTS/PARTICIPANTS: NSQIP patients over 65 years of age with patella fractures. INTERVENTION: Surgical fixation of patella fracture including extensor mechanism repair. MAIN OUTCOME MEASUREMENTS: Prolonged hospitalization, discharge to a facility, and 30-day post-operative complications. RESULTS: 1721 patients were included in the study. The average age was 74.9 years. 358 (20.8%) patients were male. 122 (7.1%) patients had a length of stay greater than 7 days. Factors associated with prolonged length of stay include pre-existing renal failure, need for emergent surgery, and time to surgery greater than 24 hours from admission. 640 patients (37.2%) of patients were discharged to a facility after surgery. Discharge to facility was associated with age >77 years, obesity, anemia, thrombocytopenia, pre-operative SIRS, and CCI > 0.5. Admission from home decreased the odds of discharge to a facility. The most common postoperative complications in this population were unplanned readmission (3.4%), unplanned reoperation (2.7%), surgical site infection (1.1%), mortality (1.0%), venous thromboembolism (0.8%), and wound dehiscence (0.2%). Complication rates increased with anemia and ASA class IV-V. CONCLUSIONS: Geriatric patients undergoing operative intervention for patella fractures are at high risk for prolonged hospitalization, discharge to facility, unplanned readmission or reoperation, and surgical site complications in the first 30 days following surgery. This study highlights modifiable and non-modifiable risk factors associated with adverse events. Early recognition of these factors can allow for close monitoring and multidisciplinary intervention in the perioperative period to improve outcomes. LEVEL OF EVIDENCE: Prognostic level III.

TNFα enhances trovafloxacin-induced in vitro hepatotoxicity by inhibiting protective autophagy.

Trovafloxacin (TVX) is associated with idiosyncratic drug-induced liver injury (iDILI) and inflammation-mediated hepatotoxicity. However, the inflammatory stress-regulated mechanisms in iDILI remain unclear. Herein, we elucidated the novel role of tumor-necrosis factor alpha (TNFα), an inflammatory stress factor, in TVX-induced in vitro hepatotoxicity and synergistic toxicity. TVX specifically induced synergistic toxicity in HepG2 cells with TNFα, which inhibits autophagy. TVX-treated HepG2 cells induced protective autophagy by inhibiting the expression of mTOR signaling proteins, while ATG5 knockdown in HepG2 cells, responsible for the impairment of autophagy, enhanced TVX-induced toxicity due to the increase in cytochrome C release and JNK pathway activation. Interestingly, the expression of mTOR signal proteins, which were suppressed by TVX, disrupted the negative feedback of the PI3K/AKT pathway and TNFα rebounded p70S6K phosphorylation. Co-treatment with TVX and TNFα inhibited protective autophagy by maintaining p70S6K activity, which enhanced TVX-induced cytotoxicity. Phosphorylation of p70S6K was inhibited by siRNA knockdown and rapamycin to restore TNFα-inhibited autophagy, which prevented the synergistic effect on TVX-induced cytotoxicity. These results indicate that TVX activates protective autophagy in HepG2 cells exposed to toxicity and an imbalance in negative feedback regulation of autophagy by TNFα synergistically enhanced the toxicity. The finding from this study may contribute to a better understanding of the mechanisms underlying iDILI associated with inflammatory stress.