Influence of Training Background on Elbow Arthroplasty Case Numbers: An Analysis of the American Board of Orthopaedic Surgery Part II Oral Examination Case List Database.

INTRODUCTION: This study aimed to evaluate the influence of training background on the frequency and indications of elbow arthroplasty performed by early-career surgeons. METHODS: A review of the American Board of Orthopaedic Surgery Part II Oral Examination Case List database from 2010 to 2021 was completed. The number of cases performed by surgeons from each individual training background were calculated and compared with the total number of surgeons who completed each fellowship during the study period. RESULTS: Hand surgeons performed the most elbow arthroplasty cases (132, 44%), but a higher percentage of shoulder/elbow surgeons performed elbow arthroplasty in comparison (15% vs. 7%). The mean number of TEA cases performed by shoulder/elbow surgeons was significantly higher than in other subspecialties (P < 0.01). However, when comparing only surgeons who performed elbow arthroplasty during the board collection period, there was no significant difference between training backgrounds (P = 0.20). DISCUSSION: While hand surgeons performed the most elbow arthroplasty cases, a higher percentage of shoulder/elbow surgeons performed elbow arthroplasty during the study period. The high prevalence of distal humerus fracture as an indication for arthroplasty reflected a shift in indications and was not related to training background.

Long-term outcomes after treatment of delirium during critical illness with antipsychotics (MIND-USA): a randomised, placebo-controlled, phase 3 trial.

BACKGROUND: Delirium is common during critical illness and is associated with long-term cognitive impairment and disability. Antipsychotics are frequently used to treat delirium, but their effects on long-term outcomes are unknown. We aimed to investigate the effects of antipsychotic treatment of delirious, critically ill patients on long-term cognitive, functional, psychological, and quality-of-life outcomes. METHODS: This prespecified, long-term follow-up to the randomised, double-blind, placebo-controlled phase 3 MIND-USA Study was conducted in 16 hospitals throughout the USA. Adults (aged ≥18 years) who had been admitted to an intensive care unit with respiratory failure or septic or cardiogenic shock were eligible for inclusion in the study if they had delirium. Participants were randomly assigned-using a computer-generated, permuted-block randomisation scheme with stratification by trial site and age-in a 1:1:1 ratio to receive intravenous placebo, haloperidol, or ziprasidone for up to 14 days. Investigators and participants were masked to treatment group assignment. 3 months and 12 months after randomisation, we assessed survivors' cognitive, functional, psychological, quality-of-life, and employment outcomes using validated telephone-administered tests and questionnaires. This trial was registered with ClinicalTrials.gov, NCT01211522, and is complete. FINDINGS: Between Dec 7, 2011, and Aug 12, 2017, we screened 20 914 individuals, of whom 566 were eligible and consented or had consent provided to participate. Of these 566 patients, 184 were assigned to the placebo group, 192 to the haloperidol group, and 190 to the ziprasidone group. 1-year survival and follow-up rates were similar between groups. Cognitive impairment was common in all three treatment groups, with a third of survivors impaired at both 3-month and 12-month follow-up in all groups. More than half of the surveyed survivors in each group had cognitive or physical limitations (or both) that precluded employment at both 3-month and 12-month follow-up. At both 3 months and 12 months, neither haloperidol (adjusted odds ratio 1·22 [95% CI 0·73-2.04] at 3 months and 1·12 [0·60-2·11] at 12 months) nor ziprasidone (1·07 [0·59-1·96] at 3 months and 0·94 [0·62-1·44] at 12 months) significantly altered cognitive outcomes, as measured by the Telephone Interview for Cognitive Status T score, compared with placebo. We also found no evidence that functional, psychological, quality-of-life, or employment outcomes improved with haloperidol or ziprasidone compared with placebo. INTERPRETATION: In delirious, critically ill patients, neither haloperidol nor ziprasidone had a significant effect on cognitive, functional, psychological, or quality-of-life outcomes among survivors. Our findings, along with insufficient evidence of short-term benefit and frequent inappropriate continuation of antipsychotics at hospital discharge, indicate that antipsychotics should not be used routinely to treat delirium in critically ill adults. FUNDING: National Institutes of Health and the US Department of Veterans Affairs.

Ultrasonographic evaluation of diaphragm thickness and excursion: correlation with weaning success in trauma patients: prospective cohort study.

PURPOSE: Prolonged mechanical ventilation (MV) subjects multiple trauma patients to ventilator-induced diaphragmatic dysfunction. There is limited evidence on the predictive role of diaphragm ultrasound (DUS) for weaning success in multiple trauma patients. Therefore, we evaluated Ultrasound of the diaphragm as a valuable indicator of weaning outcomes, in trauma patients. MATERIAL AND METHODS: This prospective cohort study included 50 trauma patients from September 2018 to February 2019. DUS was performed twice: upon ICU admission and the first weaning attempt. The diagnostic accuracy of indexes was evaluated by ROC curves. RESULTS: The study included patients with a mean age of 35.4 ± 17.37, and 78% being male. The median injury severity score was 75 (42-75). The failure group exhibited significantly lower right diaphragmatic excursion (DE) compared to the success group (P = 0.006). In addition, the failure group experienced a significant decrease in both right and left DE from admission to the first attempt of weaning from MV (P < 0.001). Both groups showed a significant decrease in inspiratory and expiratory thickness on both sides during weaning from MV compared to the admission time (P < 0.001). The findings from the ROC analysis indicated that the Rapid shallow breathing index (RSBI) (Sensitivity = 91.67, Specificity = 100), respiratory rate (RR)/DE (Right: Sensitivity = 87.5, Specificity = 92.31), and RR/TF (Thickening Fraction) (Right: Sensitivity = 83.33, Specificity = 80.77) demonstrated high sensitivity and specificity in predicting weaning outcome. CONCLUSION: In the context of patients with multiple trauma, employing DUC and assessing diaphragmatic excursion, thickness, RR/DE index, RR/TF index, and RSBI can aid in determining successful ventilator weaning.

Rat Model of Type 2 Diabetes Mellitus Recapitulates Human Disease in the Anterior Segment of the Eye.

Changes in the anterior segment of the eye due to type 2 diabetes mellitus (T2DM) are not well-characterized, in part due to the lack of a reliable animal model. This study evaluated changes in the anterior segment, including crystalline lens health, corneal endothelial cell density, aqueous humor metabolites, and ciliary body vasculature, in a rat model of T2DM compared with human eyes. Male Sprague-Dawley rats were fed a high-fat diet (45% fat) or normal diet, and rats fed the high-fat diet were injected with streptozotocin intraperitoneally to generate a model of T2DM. Cataract formation and corneal endothelial cell density were assessed using microscopic analysis. Diabetes-related rat aqueous humor alterations were assessed using metabolomics screening. Transmission electron microscopy was used to assess qualitative ultrastructural changes ciliary process microvessels at the site of aqueous formation in the eyes of diabetic rats and humans. Eyes from the diabetic rats demonstrated cataracts, lower corneal endothelial cell densities, altered aqueous metabolites, and ciliary body ultrastructural changes, including vascular endothelial cell activation, pericyte degeneration, perivascular edema, and basement membrane reduplication. These findings recapitulated diabetic changes in human eyes. These results support the use of this model for studying ocular manifestations of T2DM and support a hypothesis postulating blood-aqueous barrier breakdown and vascular leakage at the ciliary body as a mechanism for diabetic anterior segment pathology.

Using a Cone-Shaped Glass Funnel Adapter Reduces Endothelial Cell Loss Caused by Preloading Descemet Membrane Endothelial Keratoplasty Tissue.

PURPOSE: The aims of this study were (1) to compare "front" and "rear" methods for loading Descemet membrane endothelial keratoplasty (DMEK) tissue into both micro-Jones and standard-Jones tubes and (2) to evaluate the efficacy of a cone-shaped glass funnel adapter designed to make loading DMEK tissue safer for corneal endothelial cells. METHODS: The corneal endothelium was stained with 0.06% trypan blue to confirm equivalence between mate corneas. The tissues were then processed using the Iowa Lions Eye Bank standard DMEK protocol. In comparison 1, one mate was loaded into the rear of a micro-Jones or standard-Jones tube and the other was loaded into the front of the same tube. In comparison 2, one mate was loaded into the front of the micro-Jones tube and the other was loaded through the cone-shaped funnel adapter into the rear. All tissues were ejected through the front of the modified Jones tubes and assessed for endothelial cell loss (ECL) with calcein AM staining, FIJI, and Trainable Weka Segmentation; scroll widths were measured digitally. RESULTS: There were no statistically significant differences in ECL between front and rear loading [micro (N = 6 pairs): front 15.74% vs. rear 17.95%; standard (N = 6 pairs): front 19.58% vs. rear 19.17%; all P > 0.05]. DMEK scrolls loaded with the funnel adapter exhibited lower ECL compared with scrolls loaded through the front [micro (N = 8 pairs): front 13.53% vs. loading funnel 2.40%; P < 0.001]. Loading with the adapter was not faster (front 6.66 seconds vs. loading funnel 5.52 seconds; P = 0.24). CONCLUSIONS: Using a cone-shaped DMEK loading funnel may reduce ECL sustained during preloading.

Accuracy of MRI in Assessment of High-Grade Partial Distal Biceps Tears.

BACKGROUND: Magnetic resonance imaging (MRI) is commonly used to diagnose and assess the extent of partial distal biceps injuries. The aim of this study was to report on the accuracy of MRI and the effect of injury history and study timing on its performance. METHODS: A retrospective review of all patients who underwent surgical treatment of partial thickness distal biceps tears at a single center by multiple surgeons was performed. Inclusion criteria consisted of the performance of a preoperative MRI and documentation of the intraoperatively visualized extent of the tear, and 68 patients met the criteria for inclusion. A chart review was completed to evaluate the symptom duration, injury history, and tear extent. RESULTS: All patients had distal biceps tears of greater than 50% intraoperatively. However, MRI did not indicate any tearing in 20 (29%) patients, and its sensitivity for high-grade tear was 44%. Magnetic resonance imaging was significantly less likely to be read as high-grade tears in patients with insidious onset of their symptoms in comparison with patients who reported a traumatic onset (27% vs 55%, P = .024). However, the time from symptom onset to MRI did not significantly correlate with diagnosis of a high-grade tear on MRI (r = -0.15, P = .21). CONCLUSIONS: These results indicate that MRI can underreport partial distal biceps tear extent, and this more commonly occurs in patients with insidious onset of pain.

Type II Diabetes Mellitus Causes Extracellular Matrix Alterations in the Posterior Cornea That Increase Graft Thickness and Rigidity.

Purpose: There is a pressing need to investigate the impact of type II diabetes mellitus on the posterior cornea in donor tissues given its increasing prevalence and potential impact on endothelial keratoplasty surgical outcomes. Methods: Immortalized human cultured corneal endothelial cells (CECs; HCEC-B4G12) were grown in hyperglycemic media for 2 weeks. Extracellular matrix (ECM) adhesive glycoprotein expression and advanced glycation end products (AGEs) in cultured cells and corneoscleral donor tissues, as well as the elastic modulus for the Descemet membrane (DMs) and CECs of diabetic and nondiabetic donor corneas, were measured. Results: In CEC cultures, increasing hyperglycemia resulted in increased transforming growth factor beta-induced (TGFBI) protein expression and colocalization with AGEs in the ECM. In donor corneas, the thicknesses of the DM and the interfacial matrix (IFM) between the DM and stroma both increased from 8.42 ± 1.35 µm and 0.504 ± 0.13 µm in normal corneas, respectively, to 11.13 ± 2.91 µm (DM) and 0.681 ± 0.24 µm (IFM) in non-advanced diabetes (P = 0.013 and P = 0.075, respectively) and 11.31 ± 1.76 µm (DM) and 0.744 ± 0.18 µm (IFM) in advanced diabetes (AD; P = 0.0002 and P = 0.003, respectively). Immunofluorescence in AD tissues versus controls showed increased AGEs (P < 0.001) and markedly increased labeling intensity for adhesive glycoproteins, including TGFBI, that colocalized with AGEs. The elastic modulus significantly increased between AD and control tissues for the DMs (P < 0.0001) and CECs (P < 0.0001). Conclusions: Diabetes and hyperglycemia alter human CEC ECM structure and composition, likely contributing to previously documented complications of endothelial keratoplasty using diabetic donor tissue, including tearing during graft preparation and reduced graft survival. AGE accumulation in the DM and IFM may be a useful biomarker for determining diabetic impact on posterior corneal tissue.

Management of two circulations in a COVID-19 patient with secondary superinfection.

Optimal oxygenation in the intensive care unit requires adequate pulmonary gas exchange, oxygen-carrying capacity in the form of hemoglobin, sufficient delivery of oxygenated hemoglobin to the tissue, and an appropriate tissue oxygen demand. In this Case Study in Physiology, we describe a patient with COVID-19 whose pulmonary gas exchange and oxygen delivery were severely compromised by COVID-19 pneumonia requiring extracorporeal membrane oxygenation (ECMO) support. His clinical course was complicated by a secondary superinfection with staphylococcus aureus and sepsis. This case study is provided with two goals in mind (1) We outline how basic physiology was used to address life-threatening consequences of a novel infection-COVID-19. (2) We describe a strategy of whole-body cooling to lower the cardiac output and oxygen consumption, use of the shunt equation to optimize flow to the ECMO circuit, and transfusion to improve oxygen-carrying capacity when ECMO alone failed to provide sufficient oxygenation.

Reliability of the Modified Radiographic Union Score for Tibia Fractures (mRUST) for Femoral Shaft Fractures.

OBJECTIVES: To evaluate the interobserver and intraobserver reliability of the modified Radiographic Union Score for Tibia Fractures (mRUST) and the effect of rater experience in evaluation of femoral fractures. DESIGN: Retrospective cohort study. SETTING: Single Level 1 trauma center. PATIENTS/PARTICIPANTS: Patients 18-55 years of age with a femur shaft fracture. INTERVENTION: Intramedullary nail fixation. MAIN OUTCOME MEASUREMENT: Interobserver and intraobserver reliability using the intraclass correlation coefficient. RESULTS: The overall interobserver reliability was 0.96. Among fellowship-trained evaluators, the interobserver reliability was 0.94, and it was 0.92 among trainees. The overall intraobserver reliability was 0.98. The intraobserver reliability was 0.97 among fellowship-trained evaluators and 0.96 for trainees. CONCLUSIONS: These results show high interobserver and intraobserver reliability of mRUST in the evaluation of radiographic healing for femur shaft fractures treated with intramedullary nail. This high reliability was further demonstrated throughout different postoperative healing time frames. In addition, mRUST appears to be reliable when used both by trainees and experienced surgeons for the evaluation of femur shaft fractures. LEVEL OF EVIDENCE: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Clinical Examination in the Diagnosis of Anterior Cruciate Ligament Injury: A Blinded, Cross-sectional Evaluation.

OBJECTIVE: This study was conducted to compare the effectiveness of clinical tests for anterior cruciate ligament (ACL) injury. METHODS: This study prospectively evaluated the effectiveness of the Lachman test, anterior drawer test, and lever test in diagnosing ACL injury in 133 patients with knee pathology. The examiner was blinded to the patient's history, symptoms, and laterality of the pain at the time of examination. One hundred twenty-three patients in the study underwent MRI, and 90 went on to arthroscopy. The performance of the examination maneuvers and MRI was calculated. RESULTS: This study showed notable differences in sensitivity and specificity between the Lachman test and the lever test and in specificity between the anterior drawer test and the lever test. The Lachman test was also found to be more sensitive than the anterior drawer. All ACL tears diagnosed by a composite of the physical examination maneuvers were confirmed by MRI. MRI findings were concordant with arthroscopic findings in all cases. CONCLUSIONS: The Lachman test and the anterior draw test demonstrated clinical utility, but the results of the lever test should be interpreted with caution. Clinical examination was found to be highly specific but less sensitive than MRI.

Clinical Outcomes of Surgical Repair for Partial Distal Biceps Tendon Tears.

PURPOSE: The purpose of this study was to describe the outcomes of patients treated with surgical repair of partial tears of the distal biceps tendon. METHODS: The study was a retrospective review of repairs of partial tears of the distal biceps tendon performed by multiple surgeons from January 1, 2015 to October 15, 2020. Inclusion criteria consisted of preoperative magnetic resonance imaging indicative of distal biceps pathology without a complete tear and surgical treatment with intraoperative confirmation of a partial tear. The presence of preceding trauma, duration of symptoms, and postoperative complications were documented. Patients were contacted for outcome assessment using the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Patient-Reported Elbow Evaluation outcome measures. Clinical outcomes were obtained from 56 of 74 (76%) eligible patients with an average follow-up of 46 months (range: 15-85 months). RESULTS: After surgery, the median QuickDASH was 2.3 (interquartile range, 0-9.7), and the median Patient-Reported Elbow Evaluation score was 1 (interquartile range, 0-12). Postoperative QuickDASH scores were significantly lower than the preoperative scores. Known traumas preceding the symptoms and duration of symptoms before surgery were not significantly associated with the outcome. Of all eligible patients, 30 complications were reported in 25 (34%) patients and included 2 reruptures, 2 cases of heterotopic ossification, 1 deep infection, 1 case of implant irritation, 21 neuropraxias, and 3 hematomas. Five (7%) patients underwent 6 reoperations including 1 revision for a rerupture, 1 irrigation and debridement, 2 heterotopic ossification excisions, 1 hematoma evacuation, and 1 implant removal. CONCLUSIONS: The results suggest that the repair of partial distal biceps tendon tears is a viable treatment option with significant improvement in QuickDASH. There was no significant relationship between the postoperative outcome and duration of symptoms or known traumas preceding the symptoms. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Metabolic and proteomic indications of diabetes progression in human aqueous humor.

Diabetes mellitus is a multiorgan systemic disease impacting numerous ocular structures that results in significant ocular morbidity and often results in more frequent corneal and glaucoma surgeries for affected individuals. We hypothesize that the systemic metabolic and proteomic derangement observed in the progression of diabetes influences the composition of the aqueous humor (AH), which ultimately impacts the anterior segment health of the eye. To identify changes associated with diabetes progression, we mapped the metabolite profile and proteome of AH samples from patients with varying severities of type II diabetes (T2DM). Patients were classified as nondiabetic (ND or control), non-insulin-dependent diabetic without advanced features of disease (NAD-ni), insulin-dependent diabetic without advanced features (NAD-i), or diabetic with advanced features (AD). AH samples collected from the anterior chamber during elective ophthalmic surgery were evaluated for metabolite and protein expression changes associated with diabetic severity via gas chromatography/mass spectrometry and ultra-high performance liquid chromatography tandem mass spectrometry, respectively. Metabolic and proteomic pathway analyses were conducted utilizing MetaboAnalyst 4.0 and Ingenuity Pathway Analysis. A total of 14 control, 12 NAD-ni, 4 NAD-I, and 14 AD samples were included for analysis. Elevated levels of several branched amino acids (e.g., valine, leucine, isoleucine), and lipid metabolites (e.g., palmitate) were found only with increasing diabetic severity (i.e., the AD group). Similar proteomic trends were noted in amino acid and fatty acid metabolism and the unfolded protein/stress response. These results represent the first report of both metabolomic and proteomic evaluation of aqueous humor. Diabetes results in metabolic and proteomic perturbations detectable in the AH, and unique changes become manifest as T2DM severity worsens. Changes in AH composition may serve as an indicator of disease severity, risk assessment of anterior segment cells and structures, and potential future therapies.

Use of an Abductor Pollicis Brevis Tendon Slip for Reconstruction of the Radial Collateral Ligament of the Thumb Metacarpophalangeal Joint: An Anatomical Investigation.

BACKGROUND: Reconstruction of the radial collateral ligament (RCL) of the thumb metacarpophalangeal (MP) joint is commonly performed for chronic injuries. This study aims to evaluate the anatomical feasibility and reliability of using the abductor pollicis brevis (APB) tendon to reconstruct the RCL. METHODS: Ten cadaver arms were dissected to evaluate the relationship between insertions of the RCL and APB. A slip of the APB was divided from tendon and reflected proximally. The dissected tendon was deemed sufficient for reconstruction if it could be reflected to the footprint of the RCL origin. The size of the dissected APB slip was then compared with that of the RCL. RESULTS: The dissected slip of the APB could be fully reflected proximally to the RCL origin in all specimens. The APB insertion was also found to be closely approximated to the RCL insertion, averaging 2.1 mm distal and 1.8 mm dorsal. Significant differences existed between the lengths (P < .001) of the APB slip and RCL, with no significant difference in widths (P = .051). CONCLUSIONS: A sufficient APB tendon slip can be obtained to reliably reconstruct the RCL of the thumb MP. The location of the APB insertion closely approximates the RCL insertion.

Selective Patella Resurfacing in Contemporary Cruciate Retaining and Substituting Total Knee Arthroplasty: A Matched Cohort Analysis.

BACKGROUND: Leaving the patella unresurfaced in total knee arthroplasty (TKA) is increasing due to modern patella-friendly implants, awareness that complications are not uncommon with resurfacing, and knowledge that historical studies were scientifically confounded. This study examined the effect of selective patellar resurfacing on patient-reported outcome measures (PROMs) using modern implants and techniques in cohorts rigorously matched for demographics and osteoarthritis severity. METHODS: A total of 166 TKAs performed without patellar resurfacing were case-control matched to 166 TKAs with patella resurfacing. Case-control matching was based on demographics, American Society of Anesthesiology Physical Status, comorbidities, and osteoarthritis severity. No significant differences were observed between cohorts for demographics (P ≥ .347), comorbidities (P ≥ .443), or radiographic osteoarthritis severity (P ≥ .078). Radiographic alignment and prospectively collected PROMs were evaluated preoperatively and at latest clinical follow-up. RESULTS: Preoperatively, patellar tilt was less for the unresurfaced patella group (3 versus 4°, P = .003); however, postoperative patellar tilt was not different (3 versus 3°, P = .225). At a mean of 2.1 years follow-up (range, 1 to 7), University of California Los Angeles Activity Level was significantly higher for the unresurfaced patella group (6.3 versus 5.5, P = .002), but the mean group difference did not reach a minimal clinically important difference. There were no other significant differences in PROMs or reoperation rates between cohorts (P ≥ .135). CONCLUSION: In contemporary cruciate retaining and substituting TKA designs, not resurfacing the patella in select patients may achieve comparable PROMs and re-operation rates; and potentially greater activity level compared to patella resurfacing at early follow-up. LEVEL OF EVIDENCE: III.

Capnography for Monitoring of the Critically Ill Patient.

Capnography has been widely adopted in multiple clinical areas. The capnogram and end-tidal carbon dioxide offer a wealth of information, in the right clinical setting, and when properly interpreted. In this article, the authors aim to review the most common clinical scenarios during which capnography has been shown to be of benefit. This includes the areas of fluid responsiveness, cardiopulmonary resuscitation, and conscious sedation. They review the published literature, highlighting its pitfalls and identifying its limitations.

Primary Repair of Chronic Distal Biceps Tendon Tears.

BACKGROUND: This study reports the clinical results following primary repair of distal biceps tendon ruptures more 6 weeks after injury. METHODS: A retrospective review of distal biceps tendon repairs performed by 8 different hand surgeons from January 1, 2015 to October 15, 2020 was performed. Patients with complete tears surgically treated ≥6 weeks after injury without tendon graft were included. Thirty patients qualified and underwent chart review for complication and range of motion (ROM) data. They were contacted for final patient-reported outcome measures (PROMs) using Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Patient Reported Elbow Evaluation (PREE) scores. Final PROMs were obtained from 21 patients with an average follow-up of 31.3 months (range: 4-71 months). RESULTS: Average time from injury to repair was 71 days (range: 42-204). The average QuickDASH score was 6.6 (±6.2) and PREE score was 7.8 (±8.0). The amount of elbow flexion necessary to complete the repair was documented in 21 patients and averaged 64º (±10º). Postoperatively, patients achieved an average extension/flexion of 1º (±1º) to 138º (±2º) and pronation/supination of 76º (±4º) to 77º (±3º). Complications were reported in 14 patients (47%) and included 2 re-ruptures, 1 adhesive scar formation, 1 superficial infection, 1 intraoperative lateral antebrachial cutaneous nerve laceration, 12 neuropraxias, and 1 case of heterotopic ossification (HO). CONCLUSIONS: Primary repair of chronic distal biceps tendon tears greater than 6 weeks from injury demonstrated excellent PROMs and elbow ROM. However, the complication rate may be higher than early repair.

Osteoarthritic Severity in Unresurfaced Patellae Does Not Adversely Affect Patient-reported Outcomes in Contemporary Primary TKA.

INTRODUCTION: The degree of osteoarthritis (OA) acceptable to leave in a native patella during unresurfaced total knee arthroplasty (TKA) remains unknown. This study's purpose was to examine the effect of patellofemoral OA severity on patient-reported outcome measures (PROMs) in primary TKAs performed without patellar resurfacing. METHODS: One hundred ninety-three primary TKAs performed without patellar resurfacing were retrospectively reviewed. Preoperative patellofemoral OA severity was graded on severity, marginal osteophytes, joint space narrowing, and chondral damage using accepted grading systems. Patellar tilt and tibiofemoral alignment were measured radiographically. PROMs were evaluated at a minimum of 1-year follow-up. RESULTS: In multivariate regression, preoperative lateral patella Kellgren-Lawrence grade ≥2 was associated with superior change in Knee Society Score pain with level walking, higher absolute change in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (P ≤ 0.029), and knees ?always feeling normal" (odds ratio [OR] 3.12; P = 0.005). Osteoarthritis Research Society International atlas grades and Outerbridge classification scores did not significantly influence PROMs. DISCUSSION: Worse preoperative OA severity in the lateral patellar facet, graded with the Kellgren-Lawrence system, predicted superior knee-specific PROMs in patients with unresurfaced patellae after contemporary TKA. This observation supports the clinical finding that patients with more severe OA have optimized patient outcomes and highlights the minimal contribution of patella OA to knee function after primary TKA.

Pulmonary Aspects of COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a respiratory virus that gains entry via angiotensin-converting enzyme 2 (ACE2) within airway epithelium. Patients exhibit a spectrum of respiratory symptoms from asymptomatic to respiratory failure. Patient factors including obesity, tobacco use, and black race are all associated with increased ACE2 expression and may contribute to increased complications. Consolidation and ground-glass opacities on chest imaging are typical but not specific for coronavirus disease 2019 (COVID-19). Venous thromboembolism occurs infrequently when prophylactic anticoagulation is provided. However, capillary microthrombosis is nearly ubiquitous, suggesting that it contributes to hypoxemia. Remdesivir and glucocorticoids may benefit some hospitalized patients. Many of those afflicted remain symptomatic two weeks following diagnosis and continue to require health care. Total lung capacity, diffusion capacity, and maximal oxygen consumption may be reduced for months in some survivors. Lung transplant offers chronically critically ill patients new hope, and this option may have increasing potential for outpatients with COVID-19-associated fibrosis.

Reconstruction of the Thumb Metacarpophalangeal Ulnar Collateral Ligament With an Adductor Pollicis Slip: An Anatomic Evaluation.

PURPOSE: Reconstruction of the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal joint is commonly performed for chronic injuries. This study evaluates the anatomic feasibility of using a part of the adductor pollicis tendon to reconstruct UCL. METHODS: Ten cadaveric arms were dissected to evaluate the relationship between the insertions of UCL and the adductor pollicis. A slip of the adductor pollicis was divided from the tendon and transposed dorsally. The dissected tendon was deemed sufficient for reconstruction if it could be reflected to the footprint of the UCL origin. The size of the adductor pollicis slip was then compared with that of UCL. RESULTS: The dissected slip of the adductor pollicis could be fully reflected proximally to the UCL origin in all the specimens, and the insertion was also found to be closely approximated to the UCL insertion, averaging 2 mm distally and 0.6 mm dorsally. CONCLUSIONS: A sufficiently sized partial adductor pollicis tendon can be obtained to reconstruct UCL of the thumb metacarpophalangeal joint, and the location of the adductor pollicis insertion closely approximates that of the UCL insertion. CLINICAL RELEVANCE: The anatomic relationship evaluated in this study relates to a recently described method of the reconstruction of UCL of the thumb metacarpophalangeal joint that does not require free tendon harvest. This study shows that the technique is anatomically feasible.