Should a low starting point be abandoned for cannulated screw fixation of femoral neck fractures?

A validated femoral neck fracture model stabilized with three inverted cannulated screws was used to consider different intraoperative scenarios when the inferior screw hole is inadvertently started too inferiorly. These scenarios were to: (1) abandon the misplaced inferior screw hole and restart this hole more proximally, or (2) accept the mispositioned placement of the inferior screw and insert the remaining superior screws parallel or convergent to the inferior screw. Utilizing the second option and accepting the errant hole was associated with the greatest interfragmentary motion and stresses in the bone and hardware. In contrast, the first option created an improved mechanical environment for healing.

Difference in Bioimpedance Across the Knee in Un-Injured Young Adults.

Background: Knee injuries induce swelling and resolution of swelling may be a useful factor in identifying states of healing and time to return to sports activities. Recent work has suggested that bioimpedance can provide an objective measure of swelling following total knee arthroplasty (TKA) and therefore may also provide guidance for clinical decision-making following knee injury. This study measures knee bioimpedance in young, active people to help define baseline variability and factors that influence limb to limb differences. Methods: Bioimpedance was measured via sensors placed at the foot/ankle and thigh, in positions similar to those suggested for monitoring post-TKA swelling. Initial tests were performed to verify method repeatability, then bioimpedance was measured in a convenience sample of 78 subjects (median age 21yrs). The influence of age, BMI, thigh circumference, and knee function (KOOS-JR) on the impedance measures and difference in impedance between the subject's knees were examined using a generalized multivariable linear regression. Results: The repeatability study measurements were highly consistent with a COV of 1.5% for resistance and an ICC of 97.9%. Women exhibited significantly larger dominant limb impedance and larger limb to limb difference in impedance than men. Regression analysis indicated that subject sex and BMI significantly influenced bioimpedance but joint score and age did not. The limb to limb differences in impedance were small on average (<5%), with larger magnitudes of difference associated with female sex, lower knee function scores, and larger limb to limb differences in thigh circumference. Conclusion: Bioimpedance measurements across right and left knees of healthy young people were similar, supporting use of bioimpedance measures from a patient's uninjured knee as a benchmark to monitor healing of a contralateral injured knee. Future work should focus on understanding how knee function scores and bioimpedance are related, and further explore how sex and side to side anatomic differences impact the measurement. Level of Evidence: IV.

Why Do Patients Choose Skilled Nursing Facilities After Total Hip and Knee Arthroplasty?

BACKGROUND: Current research indicates that total joint arthroplasty patients who are discharged to skilled nursing facilities (SNFs) have higher complication rates as compared to home. Many factors like age, sex, race, Medicare status, and past medical history have been shown to influence discharge destination. The present study sought to gather patient-indicated reasons for SNF discharge and identify potentially modifiable factors influencing the decision. METHODS: Primary total joint arthroplasty patients were asked to complete surveys at their presurgical and 2-week postsurgical follow-up appointments. The surveys included home access and social support questions as well as patient-reported outcome measures: Patient-Reported Outcomes Measurement and Information System, Risk Assessment and Prediction Tool, Knee injury and Osteoarthritis Outcome Score for Joint Replacement, or Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement. RESULTS: Of 765 patients who met inclusion criteria, 3.9% were discharged to an SNF and these were more frequently post-THA, women, older, Black, and persons living alone. Regression analyses indicated that lower Risk Assessment and Prediction Tool score, higher age, no caregiver presence, and Black race were significantly associated with SNF discharge. Patients discharged to an SNF most commonly reported social concerns rather than medical or home access concerns as the main factor for SNF discharge. CONCLUSIONS: While age and sex are nonmodifiable factors, the availability of a caregiver and social support represents an important modifiable factor in regard to discharge destination. Dedicated attention during the preoperative planning period may help augment social support and avoid unnecessary discharges to SNFs.

Crash characteristics for classic/historic vehicles and comparisons to newer vehicles.

INTRODUCTION: Older vehicles, commonly referred to as "classic," "vintage," or "historic" vehicles (CVH), share the roadways with newer vehicles. Older vehicles lacking safety systems likely come with an increased risk of fatality, however there is no study examining the typical conditions for crashes involving CVH. METHOD: This study utilized information from crashes occurring in 2012 to 2019 to estimate fatal crash rates for vehicles grouped by model year deciles. Data from crashes documented in the National Highway Traffic Safety Administration's (NHTSA) FARS and GES/CRSS data sets were utilized to examine roadway, temporal, and crash types for passenger vehicles produced in 1970 or earlier (CVH). RESULTS: These data show CVH crashes are rare (<1% of crashes), but carry a relative risk of fatality from 6.70 (95th CI: 5.44-8.26) for impacts with other vehicles, which was the most common crash, to 9.53 (7.28-12.47) for rollovers. Most crashes occurred in dry weather, typically during summer, in rural areas, most frequently on two lane roads, and in areas with speed limits between 30 and 55 mph. Factors associated with fatality for occupants in CVH included alcohol use, lack of seat belt use, and older age. CONCLUSIONS AND PRACTICAL APPLICATIONS: Crashes involving a CVH are a rare event but have catastrophic consequences when they do occur. Regulations that limit driving to daylight hours may lower the risk of crash involvement, and safety messaging to promote belt use and sober driving may also help. Additionally, as new "smart" vehicles are developed, engineers should keep in mind that older vehicles remain on the roadway. New driving technologies will need to safely interact with these older, less safe vehicles.

Marking Pen Bacterial Contamination During Shoulder Surgery.

BACKGROUND: Equipment used to guide surgical incisions has been shown to be a source of bacterial contamination during surgery. PURPOSE/HYPOTHESIS: To compare the culture-positive rates of sterile marking pens used before and after skin preparation for shoulder surgery. It was hypothesized that there will be no difference in culture-positive rates from marking pens used after skin preparation compared with before skin preparation. STUDY DESIGN: Controlled laboratory study. METHODS: Overall, 43 consecutive patients undergoing elective shoulder surgery were enrolled prospectively into this study. Each patient provided 2 samples: study pens (from marking the surgical site incision after skin preparation) and positive control pens (from marking the surgical site incision before skin preparation). In addition, there were 43 negative control pens evaluated (straight from the packaging without any patient contact). Cultures were evaluated at 4 and 21 days, and all positive cultures were further evaluated for speciation, if able. Standard descriptive summaries and Fisher exact tests were used to compare the study samples. RESULTS: The average age of the 43 patients was 54 years (range, 18-76 years). There were 29 (67%) female patients, and 30 (70%) procedures were on the right shoulder. Of the 43 procedures performed, 29 (67.4%) were arthroscopic, 12 (27.9%) were open, and 2 (4.7%) were closed. Of the 43 study pens, 1 culture was positive for Propionibacterium acnes (2.3%). Of the 43 positive control pens, 2 cultures were positive for bacterial growth (4.7%): P. acnes and Gram-positive bacilli (no speciation could be obtained). Of the 43 negative control pens, none of the cultures were positive for bacterial growth (0%). There was no statistical difference in the culture-positive rate between the study pens and the positive or negative control pens (P ≥ .999). CONCLUSION: Study results indicated that sterile surgical marking pens used to plan incisions and to outline anatomic landmarks did not have a higher culture-positive rate compared with pens used on unprepared skin or pens straight from the packaging. CLINICAL RELEVANCE: As a precaution, sterile surgical marking pens should be discarded after use on the skin surface and not placed on the sterile field.

Safe transport of spica casted infants: Reducing the risk of traumatic injury in side impact collisions.

BACKGROUND: There is limited data on transporting small children in hip spica casts used to treat pediatric femur fractures. Specific challenges include the fixed position of the body in the casted position and the increased size of the child due to cast thickness. Additionally, children less than 2 years old are recommended to be rear facing during transportation. This traveling position requires seats that are specifically designed to accommodate the small size of the child as well as accommodate the rear facing position. While seats able to accommodate casted children are available, it is unclear if they provide adequate protection in side impact collisions for rear facing spica casted infants. Therefore, the aim of this study was to evaluate traumatic injury metrics in a side impact collision model where a spica casted infant crash dummy was restrained in currently available car seats. METHODS: Two seats designed for spica casted children (R82 Quokka, Merritt Wallenberg) and two traditional car seats (Britax Emblem, Graco Sequel) able to accommodate a casted one-year-old crash test dummy were identified. Side impact collision testing was performed with the dummy positioned in the rear facing position and injury metrics recorded. RESULTS: Testing identified contact between the dummy's head and the door panel for a specialty spica car seat without protective side-wings for the head. All other seats contained side wings and prevented door-head contact. CONCLUSIONS: Casted children should be transported in a seat able to accommodate the cast and safely restrain them. Our results demonstrate the importance of side wing protection in any seat used to transport these children as side bolsters may help decrease the potential for head contact with the door and lower the risk of severe head injury.

Crash Performance of Rear-facing Restraints With a Fracture Type Spica Casted 1-Year-Old Dummy.

BACKGROUND: Motor vehicle crashes represent a significant cause of mortality and morbidity for young children. Safely restraining a child is typically more complicated for special cases such as children treated with a hip spica cast. In the current study, hip spica casts typical for treatment of a femoral fracture were applied to a crash dummy representing the size and weight of a 1-year-old child. This spica casted dummy was used to study the performance of 4 rear-facing car seats in a series of simulated frontal impacts. METHODS: The restrained, rear-facing dummy was subjected to a frontal crash test at 30 mph (48 kph) per federal guidelines. Two of the tested car seats were specifically designed for transporting children with hip spica casts, while the other 2 were conventional seats capable of accommodating the cast. All seats were installed per the manufacturer's instructions. As a control, tests were performed without a cast using the conventional/standard seats. RESULTS: The lowest overall loading of the dummy's head, neck, and chest occurred during tests with the standard seats. While it was easier to seat the casted child in the spica-specific seats, these designs led to greater loading on the dummy's body. In a spica-specific seat, the chest acceleration values exceeded the federal limit in a test where the seat was installed in a reclined orientation that was within the manufacturer's described positioning. CONCLUSIONS: Spica-specific seats more easily accommodate the cast, but conventional seats can provide similar levels of protection in a crash. As cast and seat designs continue to evolve, hospitals might consider having a range of seats available for patient use. It is important to help caregivers make informed decisions on how and when to transport children with hip spica casts.

Low-Cost Earmuff Shown to Significantly Reduce Cast-Saw Noise.

Hearing protection devices reduce cast-saw noise. It would be helpful to identify the devices that are both effective and economical. Prior studies have shown that expensive noise-reduction headphones significantly reduced the anxiety associated with cast removal with a powered oscillating saw. The cost of such headphones, however, is a drawback for some practices and hospitals. It would be helpful to determine whether lower cost ear protection can provide effective cast-saw noise reduction. In addition, it is unclear whether the noise reduction ratings (NRRs), the average sound-level reduction provided by a hearing protection device in a laboratory test, provided by manufacturers accurately characterize the effectiveness for reducing cast-saw noise. Note that noise-cancelling devices do not carry an NRR because they are not designed as hearing protectors. Five ear protection devices with different NNRs were tested. The devices varied greatly in cost and included earplugs, low-cost earmuffs, and noise-cancelling headphones. To standardize the evaluation, each device was fitted to an acoustic mannequin with high-fidelity ear microphones while a fiberglass spica cast was cut. An additional test was run without hearing protection as a control. The low-cost devices significantly reduced the saw noise, with the exception of earplugs, which had highly variable performance. The noise reduction was similar between low-cost earmuffs and the high-cost earphones when the noise-cancelling feature was not active. Active noise cancelling provided further reductions in the noise level. Patients can experience high anxiety during cast removal. The current study shows that low-cost earmuffs significantly reduce cast-saw noise. Patient care settings may be more likely to offer hearing protection that is one twenty-fifth the cost of noise-cancelling headphones. An NRR appears to be a reliable guide for selecting hearing protection that reduces cast-saw noise.

Orthopedic Surgical Helmet Systems Significantly Impair Speech Intelligibility.

Surgical suits provide protection to orthopedic surgeons, but the suits and fan noise may interfere with communication between operative team members. The goal of this study was to quantify the fan sound and effect of the suit, fan, and N95 mask. Sound levels were measured using a specialized manikin and evaluated using preferred speech interference levels (PSILs), noise criterion (NC) ratings, and comparison with speech sound levels from the literature. Additionally, sound blocking due to the surgical suit was measured and combined effects of the fan and suit were described using a signal to noise ratio (SNR). The noise with the fan at medium and high speed was louder than average speech and the PSILs at these speeds were significantly higher than with the fan off. The fan NC rating of 50 to 60 exceeded the recommended range of 25 to 30 for operating rooms. The N95 mask, space suit, and distance between speaker and receiver all reduced the sound signal at the receiver's ear, with the worst case being full personal protective equipment on both and speaker distanced from receiver. The estimated SNR for the suit and fan system was negative for many frequency bands used in speech, indicating more noise than signal. Multiple measures indicated that the fan noises were at levels associated with speech interference. This noise combined with sound blocking provided by the suit produced SNRs commonly associated with noisy to very noisy environments. This study suggests the combined effects of the suit, fan, and distance may negatively impact operating room communication. [Orthopedics. 2021;44(4):208-214.].

Analysis of restraint use in pregnant versus non-pregnant populations involved in motor vehicle collisions.

BACKGROUND: Traumatic injuries obtained by pregnant females in motor vehicle collisions present unique treatment challenges for trauma and orthopaedic surgeons. Understanding safety choices in this population can help physicians and public safety advocates in delivering effective and targeted safety messages. METHODS: A publicly available, de-identified national data set that documents crash information (NASS-CDS) was examined to identify cohorts of pregnant and non-pregnant vehicle occupants and regression analysis employed to identify factors associated with belt non-use. RESULTS: Pregnant women were found to have significantly lower rates of belt use compared to non-pregnant females (70.0% vs. 90.3%, Rao-Scott Sample Weighted Chi-Square p = 0.0265). Logistic regression identified younger age and sitting in the back seat as associated with lower rates of belt use. CONCLUSION: Pregnant women wear belts at significantly lower frequencies than non-pregnant women and youth and second row seating increase noncompliance rates. This work suggests the need for targeted intervention strategies to improve belt compliance.

Injury metrics are altered in spica-casted versus non-casted child ATDs in side-impact collisions with door intrusion.

Objective: There is little data defining safe transport protocols for spica-casted children. A single earlier study demonstrated the presence of a body cast alters kinematics and injury metrics during simulated side-impact crashes. Since then, the National Highway Transportation Safety Administration (NHTSA) proposed a new side-impact test protocol for evaluating child restraints. This test is more severe than the earlier tests, as it simulates an impact with a door intruding into the occupant space. As no currently available child restraint system (CRS) able to accommodate a spica-casted child has been evaluated using these updated testing criteria, the objective of this study was to evaluate current restraint options in simulated side-impact collisions using an anthropomorphic test device (ATD) modeled after a 3-year-old.Methods: Four commercially available CRSs able to accommodate a spica-casted Q3s side-impact ATD were selected for testing. Side-impact testing was performed using casted and uncasted ATDs in compliance with the NHTSA proposed side-impact test. High-speed photography and ATD instrumentation were used to measure selected injury criteria.Results: HIC15 values were highest in CRSs with less robust side wings, such as the Merritt WallenburgTM (HIC15 = 1,373), which allow for the occupant to interact with the intruding door panel. Head contact with the door panel was found to correspond with high resultant neck peak force. Pelvic acceleration magnitudes were greatest for the uncasted tests. Casted tests with a CRS that included an armrest were associated with greater torso rotation in the frontal plane with the left shoulder moving toward the door panel.Conclusions: The presence of a spica cast alters injury metrics in side-impact testing. Spica specific child safety seats are not yet optimized for side-impact with door intrusion. This is due to a lack of adequate side cushion wings, which may place both casted and uncasted occupants at increased likelihood for injury through head contact with an intruding door. Additional work is needed to improve the safety of CRSs for both casted and uncasted children in side-impact collisions.

Factors influencing side air curtain deployment in rollover motor vehicle accidents.

Objective: Recent changes in FMVSS have led to the utilization of side air curtains to provide occupant retention during rollover events. However, the safety advantage provided by the air curtains relies on the vehicle system's ability to detect the rollover event and deploy the curtains. The purpose of this study is to identify crash and vehicle characteristics in motor vehicle rollovers that influence side air curtain deployment and occupant outcomes. The current study aims to improve the understanding of rollover events and inspire more robust air curtain deployment strategies.Methods: Study data were extracted from rollover cases documented in the NASS-CDS data set from 2011 to 2015. Vehicle model years of 2011 or later with side air curtains installed were examined. The presence of a rollover sensor in each vehicle was determined from vehicle content data available on the Insurance Institute for Highway Safety's crash rating website. The resulting data set contained 14,003 weighted cases of rollover accidents in which the side air curtain did not deploy (40 raw count) and 23,178 cases of deployment (80 raw count).Results: Several crash event and vehicle characteristics were similar for the nondeployed and deployed groups, including number of quarter turns, primary location of damage, initiating event for the rollover, and vehicle model year. However, the nondeployed group included significantly more passenger vehicle body types (vs. SUV or truck) and had a significantly lower rate of rollover sensor presence. Presence of a rollover sensor increased the odds air curtain deployment by a factor of 36.5 (95% confidence interval [CI], 5.06-265). Cases in which both side air curtains deployed resulted in a higher frequency of injured occupants (Maximum Abbreviated Injury Scale [MAIS] ≥ 3). However, rollover events resulting in these injuries were also associated with higher rates of impact with another object or vehicle and damage to the roof of the vehicle, suggesting a higher energy event.Conclusions: Nondeployment of the side curtain airbags in rollovers occurred more frequently in vehicles without dedicated rollover sensors, which were most frequently passenger vehicles.

Pre-bending a dynamic compression plate significantly alters strain distribution near the fracture plane in the mid-shaft femur.

This study evaluated the effect of pre-bending dynamic compression plates on fracture site compression. Recommendations of 1 to 2 mm of pre-bend have been proposed, but there does not appear to be experimental data to confirm the optimal pre-bend magnitude. Dynamic compression plating was performed on the lateral convex surface of 18 femoral analogs to fixate a simulated mid-shaft fracture. Plates with 0 mm (flat plate), 1 mm, and 2 mm of pre-bend were evaluated for their production of compression by determining the strain magnitudes for 10 equal-sized zones across the anterior cortex at the osteotomy site using digital imaging correlation. The 0 and 1 mm plates produced significantly more compression at the near cortex (p = 0.001 and p = 0.003, respectively) than the 2 mm plate. However, the 0 and 1 mm plates also created visible diastasis at the far cortex, while the 2 mm plate exhibited compression across all zones. The strain magnitudes for the 0 mm (R2 = 0.62) and 1 mm (R2 = 0.86) plates linearly and significantly decreased from the region adjacent to the plate until a region 50%-60% across the analog diameter. In contrast, the 2 mm plate exhibited uniform strains across the osteotomy site. This study demonstrates that pre-bending a dynamic compression plate 2 mm prior to fixation on a convex lateral femur provides the most compression at the far cortex. It also produces more uniform compression across the fracture when compared to 0 and 1 mm of pre-bend.

The Return on Investment of Orthopaedic Fellowship Training: A Ten-year Update.

BACKGROUND: Over 90% of graduating orthopaedic residents now pursue fellowship training, and only 15% of practicing orthopaedic surgeons now characterize themselves as generalists. Fellowship training has significant financial effects due to both opportunity cost of that year of training and changes in compensation throughout one's career. The purpose of this study was to estimate the financial return on investment by pursuing additional training in an orthopaedic fellowship versus general practice. METHODS: Using described techniques of financial analysis, net present value (NPV), internal rate of return (IRR), and break-even point were estimated over the average working career length of an orthopaedic surgeon. Compensation data were drawn from the American Medical Group Association physician compensation surveys. Seven fellowships were studied and referenced to a career in general orthopaedic practice. RESULTS: Fellowship training in spine surgery yields the highest return on investment with a break-even point of 5 years. Adult reconstruction has a positive NPV and IRR, but when corrected for number of hours worked per week offers no productivity advantage to general practice. Sports medicine and trauma offer neutral returns, but when corrected for work hours, NPV and IRR both become negative. Hand, pediatrics, and foot and ankle never break even following the loss of compensation realized during fellowship year. DISCUSSION: The recent trend across all medical specialties has been for increased fellowship training and subspecialization. There are numerous reasons to pursue fellowship training, both personal and financial. This study presents an updated estimate of the financial impact of fellowship training in orthopaedics. This analysis demonstrates that selecting different fellowships can generate positive, negative, or neutral financial returns. This study has the potential to influence residents' decisions to pursue general practice versus fellowship training and identifies economic drivers, which may lead to preferential pursuit of certain subspecialties.

Frontal Crash Injury Metrics Are Below Mandated Limits for a Spica Casted Child Dummy in Currently Available Restraints.

BACKGROUND: There is a paucity of data defining safe transport protocols for children treated with hip spica casting. Although restraint devices for casted children are available, all federally mandated testing uses a noncasted anthropomorphic test device (ATD or crash dummy). The purpose of this study was to evaluate current restraint options in simulated frontal crash testing using a casted pediatric ATD to determine injury risk to the head, cervical spine, chest, and pelvis. METHODS: Using a 3-year-old ATD, dynamic crash sled tests simulating frontal crash were performed in accordance with government safety standards. The ATD was casted in a double-leg spica and the following restraint devices were tested: a seat designed for spica casted children, a restraint vest-harness, a traditional booster seat, and 2 traditional forward-facing car seats. RESULTS: Although the presence of the cast increased many of the injury metrics measured, all seats passed current federal guidelines for the head and chest. No single seat performed best in all metrics. The greatest magnitude of neck loading and second-highest head injury criterion values were observed for the booster seat. The vest-harness produced the highest head injury criterion and the chest compression exceeded proposed federal limits. CONCLUSIONS: The results suggest safe transport in commercially available seats is possible with the child properly restrained in a correctly fitting seat. However, parents should not assume a child restraint system is appropriate for use just based on fit as, for example, seats with harnesses outperformed an easy to fit booster seat. CLINICAL RELEVANCE: Each child and the position of the child's cast are unique and discharge planning involves consideration of safe transportation. Although this study suggests several seats used to transport spica casted children pass the federal head and chest injury prevention requirements, it is important to recognize that some children may still require emergency vehicle transport.

The Effect of Booster Seat Use on Pediatric Injuries in Motor Vehicle Frontal Crashes.

BACKGROUND: Motor vehicle crashes are a significant source of pediatric mortality and morbidity. Studies indicate that booster seats significantly improve seat belt fit for children who have not attained a height of 145 cm (4' 9"). This study examined injuries occurring in booster age children up to age 12, as the majority of children do not attain 145 cm until this age. The purpose of the study was to identify differences in injuries due to the type of restraint used, with attention to musculoskeletal injuries. METHODS: Vehicle and occupant data were obtained from a publically available statistical sample of tow-away crashes. Frontal crashes over an 8-year period were examined. A data set of cases was created involving children ages 5 to 12 years who were unrestrained, restrained using the vehicle's lap and shoulder belt, and restrained using a booster seat with the vehicle's lap and shoulder seat belt. Injury severity, frequency, and patterns of distribution were compared. RESULTS: Unrestrained children experienced moderate to severe injuries 3.8 to 19 times more frequently than children using restraints. There were more injuries to the head and face in unrestrained versus restrained children, but the head and face was the most frequently injured region for all groups. There were no serious cervical spine injuries reported for any group. Lower extremity fractures were not observed in booster seat users but occurred at similar rates in both unrestrained and seat belt restrained children. These fractures occurred in older children who were involved in more severe crashes. CONCLUSIONS: Unrestrained children were more likely to experience moderate and severe injuries than restrained children. The data sample suggests that booster use may reduce the risk of extremity fracture, as there were no extremity fractures in children restrained with booster seats. CLINICAL RELEVANCE: This work provides evidence for the efficacy of booster use for preventing orthopaedic injury in children. This evidence can be used to inform parents and establish recommendations for best practices in transporting children.

Improvement in Depression and Physical Health Following Total Joint Arthroplasty.

BACKGROUND: Depression is a common co-morbid condition seen in arthroplasty patients. Pain and depression have been understood to influence one another, which may explain why this patient group experiences higher rates of depression than the general population. Arthroplasty can relieve pain and improve function, which may thereby initiate an improvement in the patient's depressive symptoms. METHODS: This retrospective study examined physical and mental domain outcomes of Short Form-36 health-related quality of life questionnaire among 146 patients who underwent primary hip or knee arthroplasty for osteoarthritis at a single institution during 2001-2004. These patients were classified into "depressed/anxious" and "non-depressed" groups based on their pre-operative mental component summary (MCS), with MCS < 42 defining depression. MCS and the subscales from the 36-Item Short-Form Health Survey form expected to be influenced by arthroplasty, Physical Function, Pain, and Role Physical were examined at 3 months and 1 year post-operative. RESULTS: At 1 year, 66.7% of the "depressed/anxious" group reported MCS > 42, suggesting improvement of their depressive symptoms. Both groups reported similar improvements in their 36-Item Short-Form Health Survey subscale scores for Pain and Physical Function. However, the depressed group's scores were lower than the non-depressed group's at all time points. CONCLUSION: Arthroplasty significantly improved Physical Function and Pain in depressed patients, while their depressive symptoms improved. This improvement may be in response to the resolution of physical symptoms and represents an additional benefit to this elective surgery. Further studies, in larger populations, are needed to establish patient characteristics associated with non-resolution of depressive symptoms and the role of mental health interventions to optimize outcomes for hip and knee arthroplasty patients.

Reactions to psychological contract breaches and organizational citizenship behaviours: An experimental manipulation of severity.

Grounded in affective events theory, we investigated the effects of experimentally manipulated psychological contract breaches on participants' feelings of violation, subsequent perceptions of psychological contract strength, and organizational citizenship behaviours in a sample of working adults. Results support previous findings that pre-existing relational psychological contract strength interacts with severity of unmet promises or expectations. Specifically, individuals with high relational contracts who experience low severity of unmet promises/expectations have the lowest breach perceptions, whereas individuals with high relational contracts who experience more severe levels unmet promises/expectations experience the highest level of breach perceptions. Results also support the concept of a breach spiral in that prior perceptions of breach led to an increased likelihood of subsequent perceptions of breach following the experimental manipulation. Furthermore, consistent with affective events theory, results support the argument that a psychological contract breach's effect on specific organizational citizenship behaviours is mediated by feelings of violation and the reassessment of relational contracts. These effects were present even after controlling for the direct effects of the manipulated severity of unmet promises/expectations.

Temporal Variation in Ankle Fractures and Orthopedic Resident Program Planning in an Urban Level 1 Trauma Center.

Previous studies have described the mechanism of ankle fractures, their seasonal variation, and fracture patterns but never in conjunction. In addition, the cohorts previously studied were either not from trauma centers or were often dominated by low-energy mechanisms. The present study aimed to describe the epidemiology of ankle fractures presenting to an urban level 1 trauma center. The records from an urban level 1 trauma center located in the Midwestern United States were retrospectively reviewed, and the injury mechanism and energy, time of injury, day of week, month, and patient characteristics (age, gender, comorbidities, smoking status) were collected. The fractures were classified using the AO (Arbeitsgemeinschaft für Osteosynthesefragen), Lauge-Hansen, and Danis-Weber systems. Of these systems, the Lauge-Hansen classification system resulted in the greatest number of "unclassifiable" cases. Most ankle fractures were due to high-energy mechanisms, with motor vehicle collisions the most common high-energy mechanism. The review found that most ankle fractures were malleolar fractures, regardless of the mechanism of injury. The ankle fracture patients had greater rates of obesity, diabetes, and smoking than present in the region where the hospital is located. The fractures were most likely to occur in the afternoon, with more fractures presenting on the weekend than earlier in the week and more fractures in the fall and winter than in the spring and summer. The temporal variation of these fractures should be considered for health services planning, in particular, in regard to resident physician staffing at urban level 1 trauma centers.

The New Surgical Technique for Improving Total Knee and Hip Arthroplasty Outcomes: Patient Selection.

BACKGROUND: Inclusion of patient satisfaction scores in setting reimbursements has been suggested by health care policy makers to contain cost and improve outcomes. The Short Form 36 Health Survey (SF-36) score provides a health-related quality of life (HRQoL) measure of arthroplasty outcome. Although previous work identified factors that influence this score for hip and knee arthroplasty patients, they did not focus on how a surgeon might use this information in a clinical setting. The present study examined whether relatively simple criteria might identify patients more likely to experience minimal HRQoL improvement. METHODS: "Improvements" in SF-36 composite physical scores and subscales were calculated from the difference between initial (preoperative) and SF-36 scores at 1 year. The rates of achieving a clinically significant improvement were compared between patient groups. RESULTS: After knee arthroplasty, women and younger patients achieved a clinically significant improvement in physical function more frequently than men and older patients (P = .04 and .02, respectively). The largest differences in improvement occurred between the diabetic and nondiabetic groups (P = .001), where the diabetic patients with ≥2 additional comorbidities demonstrated the lowest rate of achieving a clinically significant improvement in physical function and bodily pain. In comparison, in hip patients only age had significant influence on gains in physical function, but this did not alter the rate at which patients achieved a clinically significant improvement. CONCLUSION: These data indicate simple screening criteria can identify patients where arthroplasty might provide marginal HRQoL improvement. They suggest HRQoL-based reimbursement incentives will favor practices with younger, healthier patient populations.