Demographics and Clinical Characteristics of Adult Patients Hospitalized due to COVID-19 in a Rural/Suburban Integrated Health System in Southcentral Pennsylvania, March Through May 2020.

Existing characterizations of coronavirus disease 2019 (COVID-19) admissions have occurred primarily in urban settings. This report describes demographic and clinical characteristics of the first COVID-19 patients presenting to a 6-hospital integrated health care system in rural/suburban southcentral Pennsylvania. Medical records of adult patients admitted with COVID-19 between March and May of 2020 were retrospectively reviewed for demographics, symptomatology, imaging, and lab values. Results were largely consistent with previous studies, although gastrointestinal manifestations were more prevalent, with diarrhea reported in 25.4% of patients hospitalized due to COVID-19. Nursing home patients represented 10.1% of admissions but accounted for 35.5% of total deaths in our sample. Patients self-identifying as Hispanic were disproportionately affected. Although Hispanic ethnicity was self-reported in only 9% of the community population, Hispanic patients accounted for 34% of admissions. Our data provide a unique focused review of hospitalized COVID-19 patients in a rural/suburban setting.

Nonagenarian hip fractures: Morbidity and mortality at a single institution.

OBJECTIVES: The incidence of hip fractures continues to rise dramatically, but few studies have examined these injuries in the population of individuals over 90 years of age, which is one of the fastest growing populations. We present the largest such study specifically examining hip fractures in the super-elderly. METHODS: A review of 216 hip fracture patients over 90 years of age were examined for immediate postoperative complications and in-house, 30-day, and 1-year mortality. RESULTS: Overall 1-year mortality was 38.1%. Statistically-significant risk factors for 1-year mortality included oncologic fracture, dementia, and CHF. Fracture classification and hospital length of stay were associated with perioperative complications including anemia and pneumonia. CONCLUSION: The nonagenarian hip fracture is associated with a higher 1-year mortality than prior reported rates of mortality for elderly hip fractures. Factors previously reported to influence the risk of 1-year mortality in hip fractures are not observed in the super-elderly.

The hidden blood loss in proximal femur fractures is sizeable and significant.

BACKGROUND: Patients sustaining hip fractures experience blood loss as a direct result the fracture independent of surgery. The objective of this study was to quantify the expected non-surgical blood loss for proximal femur fractures using hemoglobin values. METHODS: A retrospective chart review of patients at a level 1 trauma center sustaining proximal femur fractures between October 2015 and January 2018 was performed. Patients were ≥30 years of age, had sustained intertrochanteric, subtrochanteric, or femoral neck fractures and had hemoglobin values documented at admission and after 12 h but before surgery. Patients with concomitant fractures, other hemorrhagic injuries, or blood transfusions before their second hemoglobin result were excluded. A multivariate linear regression model was constructed to evaluate the predictive ability of age, sex, BMI, number of comorbidities, fracture type, anticoagulation/antiplatelet therapy, admission hemoglobin, timing of surgical intervention and changes in electrolyte levels on subsequent hemoglobin values. Hemoglobin changes were compared between intertrochanteric, subtrochanteric, and femoral neck fractures and anticoagulant therapy types with Welch's tests. RESULTS: 119 patients were included. The mean age was 80.9 ± 10.81 years. Nearly 53% of subjects were using anticoagulation therapy. The mean drop in hemoglobin was 1.4 ± 1.03 g/dL. The multivariate linear regression model had statistically significant predictive ability (R = 0.91, p < 0.001). Independent predictors of hemoglobin decrease were number of comorbid conditions (p = 0.02), admission hemoglobin reading (p < 0.001), fracture type (p = 0.02), and time from admission to surgery (p = 0.03). Intertrochanteric fractures demonstrated the largest hemoglobin drops. Anticoagulation therapy had no effect on subsequent hemoglobin. CONCLUSION: Proximal femur fractures cause a significant amount of blood loss prior to surgical intervention. Patients at particular risk include those with comorbidities, intertrochanteric fractures, low admission hemoglobin values, and increased time to surgery. The identification of demographic, fracture type, and treatment characteristics may help surgeons identify patients at the greatest risk for blood loss, and provide more effective perioperative care.

Ultrasound-Guided Percutaneous Tenotomy and Its Associated Pain Reduction and Functionality Outcomes in Nonelite Active Adults.

OBJECTIVE: The aim of this study was to evaluate changes in pain and functionality after ultrasound-guided percutaneous tenotomy (USGPT) for treatment of tendinopathy. DESIGN: This was a prospective cohort study of patients undergoing USGPT as an alternative to surgery. Nonelite, active adults completed pain and functionality assessments before USGPT. The visual analog scale (VAS) was used to quantify pain. The Lower Extremity Functionality Scale and the Disabilities of the Arm, Shoulder, and Hand were used to evaluate functionality. Repeat VAS scores were obtained at 1 wk, 1 mo, 2 mos, 3 mos, 6 mos, and 1 yr postprocedure, and repeat functionality assessments, at 1 yr postprocedure. Changes in VAS and functionality were analyzed with paired-sample t-tests. RESULTS: A total of 103 subjects (61 women, 42 men) underwent USGPT in the following tendons: Achilles, patellar, plantar fascia, flexor carpi ulnaris, extensor carpi radialis brevis, and supraspinatus. Subjects experienced statistically significant decreases in VAS and functionality scores at all time points. The mean VAS score decreased from 7.3 to 3.8 (P < 0.0001) 1 wk postprocedure, with a 5.8-point mean decrease at 1 yr (P < 0.0001). Lower Extremity Functionality Scale scores improved from 42.5 to 65.8 (P < 0.001) and Disabilities of the Arm, Shoulder, and Hand scores improved from 41.5 to 10.4 (P < 0.001) at 1 yr. CONCLUSION: Recipients of USGPT procedures can expect to benefit from less invasive procedures and improved pain and functionality without invasive surgical procedures.

Closed Internal Degloving of the Toes: A Case Report.

Closed degloving injuries are uncommon, high-energy injuries that separate the bony structures from the soft tissue and frequently result in amputation. Because the epidermis is often intact, it is difficult to visualize the extent of the soft tissue damage. Although there is no gold standard of treatment for closed degloving injuries at present, previous cases have reported that neurovascular presentation is a key predictor of amputation Herein, we report a closed degloving injury involving the second through fifth phalanges of the left foot following a crushing injury with a forklift. Despite adequate capillary refill upon initial presentation, the patient ultimately underwent transmetatarsal amputation.

Implications of Admission and Surgical Timing on Hospital Length of Stay in Patients with Hip Fractures.

INTRODUCTION: Hospital reimbursements for geriatric hip fractures are contingent on patient outcomes and hospital length of stay (LOS). This study examined if the day of the week (DOTW) and time of day (TOD) of both admission and surgery are associated with increased LOS. METHODS: LOS, time from admission to surgery, DOTW of admission/surgery, TOD of admission/surgery, and demographics were retrospectively collected. The average LOS was 4.5 days. Patients were grouped into cohorts of LOS 1 to 4 days (short-stay) and 5 to 12 days (long-stay). The percentage of short-stay patients was compared with the percentage of long-stay patients for each DOTW/TOD of admission/surgery with chi square tests. RESULTS: One hundred patients were included, 58 short stays and 42 long stays. Both groups were similar regarding demographics. Long-stay patients were 4.2 times more likely to have been admitted ([95% confidence interval 1.2 to 14.6], P = 0.02) and 4.8 times as likely to have undergone surgery ([95% confidence interval 1.0 to 5.6], P = 0.01) on a Thursday, respectively. TOD of admission/surgery did not demonstrate any association with LOS. DISCUSSION: Thursday admission/surgery was associated with longer LOS. Delayed surgical optimization coupled with insurance companies' observance of regular business hours may delay admission to inpatient rehab or skilled nursing facilities, resulting in avoidable healthcare expenditures.

Early Sport Specialization in Elite Weightlifters: Weightlifting Injury Occurrence and Relevant Opinions.

ABSTRACT: Bush, CM, Wilhelm, AJ, Lavallee, ME, and Deitch, JR. Early sport specialization in elite weightlifters: weightlifting injury occurrence and relevant opinions. J Strength Cond Res 35(11): 3260-3264, 2021-Sports specialization has been associated with increased injury and burnout. This study sought to determine the age, rate of injury, influence to specialize, and opinions surrounding the impact of sports specialization in attainment of elite-level weightlifting status. A link to an anonymous survey was distributed to the top 20 weightlifters in each weight class (8 male and 7 female weight classes). The survey questioned athletes about both age and motivation to specialize, previous injuries and/or surgeries, and level of competition. Injuries and surgeries were compared between those who specialized at the Youth level (≤age 16), Junior level (ages 17-20), and nonspecialized weightlifters. One hundred forty-one athletes (47.0%) completed the survey. Sixteen subjects (11.3%) specialized at the Youth level, 18 (12.8%) specialized at the Junior level, and the remaining 107 (75.9%) did not specialize before age 21. There was a statistically significant difference in the occurrence of injury before age 21 between weightlifters specializing at the Youth level and those who did not specialize (Χ2(1) = 22.4, p < 0.0001). There were no statistically significant differences in serious injury after age 21 between groups. Weightlifters cited primarily themselves (45.4%) or coach (43.1%) as a driving influence to specialize. The majority of athletes (68.8%) felt that specializing during the Youth age group was not necessary to achieve elite status. Despite a relatively small sample size, injuries occurred more frequently in weightlifters specializing at younger ages, suggesting that risks associated with early sport specialization also apply to weightlifters. These risks should be considered before implementing an early specialization training regimen.

A Proposal for a Standardized Nomenclature of the C-arm Movements.

No formal didactic source exists concerning terminology for movement of the C-arm in the operating room (OR). Many terminologies exist, breeding confusion among OR staff. The objective of this study was to survey the existing C-arm movement terminologies among orthopaedic surgeons and radiologic technologists and propose a standardized nomenclature moving forward. Methods: Forty-six orthopaedic surgeons and 70 radiologic technologists were surveyed. Pertinent product manuals and literature from PubMed were reviewed to find existing terms for the C-arm movement. A focus group of orthopaedic surgeons and radiologic technologists was formed and a standardized nomenclature of the C-arm terminology was developed using the Delphi method. Results: The survey response rate was 71%. The mean percentage of agreement on terms to describe movement was 47% (range, 13% to 83%). Agreement on terms to describe direction was 46% (range, 23% to 73%), and multiple frames of reference were described. No consensus was found by searching the product manuals. Using the Delphi method, we arrived at a standardized nomenclature for the C-arm movement that is reproducible and familiar. Discussion: A standardized terminology for the C-arm movement is described that will help fill a void in OR communication, combat confusion, and provide reproducible results during orthopaedic cases.

Early Sports Specialization in Elite Wrestlers.

BACKGROUND: Sports specialization is becoming an increasingly common training strategy in young athletes. Very little research currently exists examining the occurrence of serious injury (>3 months off sport or loss of season) in elite-level wrestlers who specialize early (before age 12 years). HYPOTHESIS: Wrestlers who specialize early will sustain more serious injuries than wrestlers who specialize at age 12 years or older. STUDY DESIGN: Descriptive epidemiological study. METHODS: We sent an anonymous online survey to a total of 312 elite-level wrestlers (National Collegiate Athletic Association Division I athletes and World/Olympic team members) containing questions documenting age of specialization and number of serious injuries sustained. The number of serious injuries both before and after starting college were compared between wrestlers specializing at <12 years old and ≥12 years old using an independent-samples t test. Respondents' opinions on the necessity of early specialization and their primary source of encouragement to specialize were also reported. RESULTS: A total of 143 wrestlers completed the survey, for a total response rate of 46%. Thirty-six (25%) wrestlers specialized at <12 years old. The early specialization group sustained significantly more serious injuries than the late specialization group (1.14 vs 0.60; P = 0.035). Sixty-two (43%) believed early specialization was necessary to achieve elite-level status. The decision to specialize was encouraged primarily by the athlete (78/143; 55%), parents (37/143; 26%), and coaches (22/143; 15%). CONCLUSION: Elite wrestlers who specialize prior to age 12 years sustain a greater number of serious injuries before starting college than those who specialize at or after the age of 12 years. CLINICAL RELEVANCE: Athletes, coaches, and parents should consider the risk of injury before adopting a wrestling-specialized training strategy at a young age.

Palliative Management of Nonoperative Femoral Neck Fractures With Continuous Peripheral Indwelling Catheters: Case-Control Series.

INTRODUCTION: This case-control study evaluates the success of indwelling pain catheters in nonoperatively treated femoral neck fractures (FNFs) for end-of-life pain management. METHODS: Patients older than 65 years with nonoperatively treated FNFs were retrospectively identified at a level 1 trauma center between March 2012 and September 2015. Twenty-three received indwelling continuous peripheral pain catheters (experimental) and 10 received traditional pain control modalities (control). Pain scores 24 hours before/after pain management interventions, ambulation status at admission and discharge, mortality at 30 days/1 year, and length of hospital stay (LOS) were compared between treatment groups. RESULTS: The experimental and control groups were similar with respect to demographics, differing only in pre-fracture ambulatory status (P = .03). The 30-day mortality was 52% versus 50% (odds ratio, OR: 1.1 [95% confidence interval, CI: 0.25-4.82], P = .99) and 1-year mortality was 87% versus 80% (OR: 1.67 [95% CI: 0.23-11.9], P = .63) for experimental and control groups, respectively. The LOS did not statistically significantly differ for experimental and control groups (5.3 ± 3.56 days vs 3.8 ± 1.81 days, P = .15), respectively. The experimental group experienced twice the improvement in ambulation status (1.0 ± 0.56 vs 0.5 ± 0.71, P = 0.03) and greater improvement in pain scores (4.5 ± 2.19 vs 1.2 ± 2.72, P = .002). DISCUSSION: Operative management of FNFs may not be indicated in patients with advanced age and comorbidities. Regardless, these patients require pain palliation and early mobilization while minimizing hospital LOS and opiate consumption. CONCLUSION: This case-control study demonstrates significant improvement in both pain level and ambulatory status for patients treated with indwelling continuous peripheral catheters. Future studies should further evaluate with a larger sample size; however, this study provides an excellent launching point for palliative management of this complex population.

Comparing fracture patterns of younger versus older riders involved in nonfatal motorcycle accidents.

OBJECTIVE: The motorcyclist demographic is shifting to a larger proportion of riders over the age of 40. We sought to identify differences in orthopedic injury distribution and severity between 3 age cohorts and identify independent factors that contribute to fractures following a motorcycle collision (MCC). METHODS: A trauma registry at a level 1 trauma center was queried for motorcycle-related orthopedic injuries between January 1, 2008, and December 31, 2014. Subjects were stratified into 3 age groups: Young (<40 years), middle-aged (40-59 years), and elderly (≥60 years). Age groups were compared with respect to gender, weight, mechanism of collision, helmet use, Glascow Coma Scale (GCS), fracture type and location, Injury Severity Score (ISS), and hospital length of stay (LOS). A logistic regression model was constructed to identify independent factors that contribute to fractures following MCCs. RESULTS: Five hundred sixty-seven patients received care for motorcycle-related injuries (219 young, 264 middle-aged, and 84 elderly). Patients were predominantly male (88.7%), were wearing a helmet at the time of collision (58.0%), and sustained a mean of 1.48 fractures per patient. The primary mechanism of collision was noncollision transport accidents (41.4%). Elderly riders weighed significantly more than middle-aged and young riders (P < .0001). There was a significant difference in mean GCS between age groups (P = .02), with elderly patients demonstrating the highest mean GCS (14.0 ± 3.3). Young patients sustained no fractures most frequently when compared with middle-aged and elderly riders (P = .002). There was a significant difference in the percentage of patients sustaining right-sided, lower body fractures between age groups (P = .02) for elderly, middle-aged, and young patients, respectively. There was also a significant difference between age groups in the percentage of riders sustaining fractures other than those of the extremities, pelvis, or spine (P = .0005). Only age was identified as an independent predictor of sustaining a fracture (P = .008). CONCLUSIONS: Elderly patients sustained fractures more frequently. There was no difference between age groups with respect to injury severity. Mechanism of collision may have more influence than age with respect to fracture type and location. Further research is warranted to develop a more widely generalizable characterization of motorcycle collision injury patterns, risk factors, and patient characteristics.

Looking for Holes in Sterile Wrapping: How Accurate Are We?

BACKGROUND: Defects in sterile surgical wrapping are identified by the presence of holes through which light can be seen. However, it is unknown how reliably the human eye can detect these defects. QUESTIONS/PURPOSES: The purpose of this study was to determine (1) how often holes in sterile packaging of various sizes could be detected; and (2) whether differences in lighting, experience level of the observer, or time spent inspecting the packaging were associated with improved likelihood of detection of holes in sterile packaging. METHODS: Thirty participants (10 surgical technicians, 13 operating room nurses, seven orthopaedic surgery residents) inspected sterile sheets for perforations under ambient operating room (OR) lighting and then again with a standard powered OR lamp in addition to ambient lighting. There were no additional criteria for eligibility other than willingness to participate. Each sheet contained one of nine defect sizes with four sheets allocated to each defect size. Ten wraps were controls with no defects. Participants were allowed as much time as necessary for inspection. RESULTS: Holes ≥ 2.5 mm were detected more often than holes ≤ 2 mm (87% [832 of 960] versus 7% [82 of 1200]; odds ratio, 88.6 [95% confidence interval, 66.2-118.6]; p < 0.001). There was no difference in detection accuracy between OR lamp and ambient lightning nor experience level. There was no correlation between inspection time and detection accuracy. CONCLUSIONS: Defects ≤ 2 mm were not reliably detected with respect to lighting, time, or level of experience. Future research is warranted to determine defect sizes that are clinically meaningful. LEVEL OF EVIDENCE: Level II, diagnostic study.