Summary
We evaluated the utility of a palliative care consult (PCC) in high-risk hip fracture patients. The main result was that a PCC reflects certain risk factors for post-surgical complications ...and is associated with a delay to surgery in the high-risk patient population that it served.
Purpose
The objective of this study was to identify risks of complications in surgically managed hip fractures and determine the utility of a PCC in this population, particularly regarding time to the operating room (OR).
Methods
Retrospective cohort at a Level I academic trauma center.
Results
Four hundred sixty-two patients were treated surgically for hip fracture. Decreased pre-injury ambulatory status (OR 2.18, 95% CI 1.13–4.20,
p
= .02), time to OR > 48 h (OR 4.76, 95% CI 1.43–15.87,
p
= .011), and obtaining a pre-operative PCC (OR 3.03, 95% CI 1.34–6.85,
p
= .008) were independent risk factors for post-surgical complications. Multivariate risk factors for obtaining a PCC included older age (OR 1.1, CI 1.0–1.1,
p
= .007), pre-injury ambulatory status (OR 2.2, CI 1.3–3.9,
p
= .005), renal failure (OR 3.1, CI 1.1–9.0,
p
= 0.032), and higher ASA category (OR 2.6, CI 1.2–5.5,
p
= .014). A delay of more than 48 h was associated with being male ( OR 4.6, CI 1.4–15.0,
p
= .013) or having obtained a PCC (OR 5.5, CI 1.4–22.7,
p
= .017).
Conclusions
Obtaining a PCC can reflect risks of complications and mortality. It is a valuable resource for use in high-risk patients who are inherently at risk for delays to surgery and should be used judiciously.
Posttraumatic Cubitus Varus: Respect the Columns Schlauch, Adam M; Manske, Mary Claire; Leshikar, Holly B ...
Journal of pediatric orthopaedics,
07/2024, Letnik:
44, Številka:
6
Journal Article
Recenzirano
Posttraumatic cubitus varus is a multiplanar deformity that results from an improperly reduced supracondylar humerus fracture. The prevention of posttraumatic cubitus varus hinges on the stable ...restoration of all 3 columns of the distal humerus while avoiding malrotation. The collapse of any column leads to varying degrees of deformity in the coronal, sagittal, and/or axial plane. The purpose of this article is to explain the pattern of the deformity and use this to summarize preventative tactics for avoiding its described sequelae. We also summarize, illustrate, and present case examples for the various osteotomies used to correct the deformity, and speculate future directions.
To compare perioperative, 90-day, and 1-year postoperative complications and outcomes between the direct anterior approach (DAA) and posterior approach (PA) for total hip arthroplasty (THA) in ...geriatric patients with displaced femoral neck fractures (FNF).
Retrospective Cohort Study.
Multicenter Healthcare Consortium.
709 patients > 60 years of age with acute displaced FNF between 2009 and 2021.
THA using either DAA or PA.
Rates of postoperative complications including dislocations, reoperations, and mortality at 90 days and 1 year postoperatively. Secondary outcome measures included ambulation capacity at discharge, ambulation distance with inpatient physical therapy, discharge disposition, and narcotic prescription quantities (morphine milligram equivalents MME).
Through a multivariable regression analysis, DAA was associated with significantly shorter operative time (B = -6.89 minutes; 95% CI, -12.84 to -0.93; P = 0.024), lower likelihood of blood transfusion during the index hospital stay (aOR = 0.54; 95% CI, 0.27 to 0.96; P = 0.045), and decreased average narcotic prescription amounts at 90 days (B = -230.45 MME; 95% CI, -440.24 to -78.66; P = 0.035) postoperatively. There were no significant differences in medical complications, dislocations, reoperations, and mortality at 90 days and 1 year postoperatively.
When comparing the DAA versus PA for THA performed for displaced FNF, DAA was associated with shorter operative time, a lower likelihood of blood transfusion, and lower 90-day postoperative narcotic prescription amounts.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
External fixation of unstable ankle injuries is commonly done by orthopaedic surgeons. An improper technique can negate the benefits of the procedure and necessitate revision. This study sought to ...determine the risk factors for revision of external fixation of unstable ankle injuries.
Retrospective cohort at a level I academic trauma center of 120 consecutive patients underwent external fixation of an unstable ankle injury. Exclusion criteria included external fixation for reason other than fracture, inadequate intraoperative imaging, skeletal immaturity, and follow-up less than 30 days. Primary outcome measurement was revision of external fixation within 30 days.
Ninety-seven patients met inclusion criteria. Eighteen (18.6%) underwent revision within 30 days of whom 5 (28%, P < 0.001) had a poor reduction intraoperatively. No patients with a good reduction required revision. Revised patients had a significantly higher talar tilt (P < 0.001) and were more likely to lack a first metatarsal pin (P = 0.018). Multivariate analysis revealed talar tilt >0.5° (odds ratio, 22.62; 95% confidence interval, 6.52 to 50.63) as an independent risk factor for revision.
For external fixation of unstable ankle injuries, poor reduction quality is a risk factor for need for revision surgery. Orthopaedic surgeons should be critical of their final intraoperative assessment to prevent revision.
•One of the most prognostic independent risk factors for developing distal femoral nonunion is obesity.•Increased axial load substantially increases interfragmentary strain, which can be normalized ...by shortening the working length and/or increasing the screw density of the construct.•Decreasing the working length had a larger effect than increasing the screw density on interfragmentary gap stiffness.
Distal femur fractures are difficult to successfully treat due to high rates of nonunion. Obesity is an independent prognostic risk factor for nonunion. Advances in finite element analyses (FEAs) have allowed researchers to better understand the performance and behavior of constructs at the bone-implant interface under a variety of conditions. The purpose of this study is to determine the impact of body weight on fracture strain in a lateral locking plate construct for supracondylar femur fractures and whether additional construct rigidity is beneficial to optimize fracture strain in high body mass patients.
We hypothesized that increased loads would produce a higher interfragmentary strain (IFS), which could be decreased by shortening the working length of the construct.
A 3D finite element analysis was performed on two separate femur models with a comminuted supracondylar distal femur fracture fixed with a lateral distal femoral locking plate in bridging mode with Ansys software. Axial forces were varied to recreate the effect of load from normal and high body mass patients. Working length and screw density of the construct were varied for each condition. Measurements of interfragmentary strain and shear motion (SM) were compared.
Doubling the axial load from 70kg (control) to 140kg (high body mass) increased the interfragmentary strain by an average of 76% for the three working lengths (3.38%±1.67% to 4.37%±0.88% at the baseline working length (BWL), 1.42%±1.00% to 2.87%±2.02% at the intermediate working length (IWL) and 0.62%±0.22% to 1.22%±0.42% at the short working length (SWL)). On average, decreasing the working length in the 140kg load reduced the mean IFS to within 15% of the mean IFS of the 70kg load at the longer working length (2.87%±2.02% at IWL 140kg versus 3.38%±1.67% at BWL 70kg and 1.22%±0.45% SWL 140kg versus 1.42±1.00% IWL 70kg).
Increased axial load increases interfragmentary strain in an AO/OTA 33A distal femur fracture fixed with a lateral distal femoral locking plate. Decreasing the working length of the fixation construct in the high body mass model decreased interfragmentary strain. Higher loading conditions reflective of high body mass patients should be considered in studies investigating optimization of fracture strain.
V; Finite Element Analysis (FEA).
Open reduction and internal fixation of distal radius fractures is one of the most common operations for orthopaedic surgeons. A vital step of the operation is restoring radial height, which can be ...challenging if the surgeon is operating alone. To address this, we present a novel surgical technique called the distal radius mini distractor. The technique utilizes a compression / distraction device in tandem with a volar locking plate to aid in the reduction of impacted distal radius fractures. The written technique guide is presented alongside intra-operative surgical pictures and fluoroscopy. The objective of this article is to introduce the mini distractor technique, which can be of particular use for the surgeon operating without assistance.
Abstract SummaryWe evaluated the utility of a palliative care consult (PCC) in high-risk hip fracture patients. The main result was that a PCC reflects certain risk factors for post-surgical ...complications and is associated with a delay to surgery in the high-risk patient population that it served.PurposeThe objective of this study was to identify risks of complications in surgically managed hip fractures and determine the utility of a PCC in this population, particularly regarding time to the operating room (OR).MethodsRetrospective cohort at a Level I academic trauma center.ResultsFour hundred sixty-two patients were treated surgically for hip fracture. Decreased pre-injury ambulatory status (OR 2.18, 95% CI 1.13–4.20, p = .02), time to OR > 48 h (OR 4.76, 95% CI 1.43–15.87, p = .011), and obtaining a pre-operative PCC (OR 3.03, 95% CI 1.34–6.85, p = .008) were independent risk factors for post-surgical complications. Multivariate risk factors for obtaining a PCC included older age (OR 1.1, CI 1.0–1.1, p = .007), pre-injury ambulatory status (OR 2.2, CI 1.3–3.9, p = .005), renal failure (OR 3.1, CI 1.1–9.0, p = 0.032), and higher ASA category (OR 2.6, CI 1.2–5.5, p = .014). A delay of more than 48 h was associated with being male ( OR 4.6, CI 1.4–15.0, p = .013) or having obtained a PCC (OR 5.5, CI 1.4–22.7, p = .017).ConclusionsObtaining a PCC can reflect risks of complications and mortality. It is a valuable resource for use in high-risk patients who are inherently at risk for delays to surgery and should be used judiciously.
Focal amplification of chromosome 1q23.3 in patients with advanced primary or relapsed urothelial carcinomas is associated with poor survival. We interrogated chromosome 1q23.3 and the nearby focal ...amplicon 1q21.3, as both are associated with increased lymph node disease in patients with urothelial carcinoma. Specifically, we assessed whether the oncogene
that resides in 1q21.3 and the genes that reside in the 1q23.3 amplicon were required for the proliferation or survival of urothelial carcinoma. We observed that suppressing MCL1 or the death effector domain-containing protein (DEDD) in the cells that harbor amplifications of 1q21.3 or 1q23.3, respectively, inhibited cell proliferation. We also found that overexpression of MCL1 or DEDD increased anchorage independence growth
and increased experimental metastasis
in the nonamplified urothelial carcinoma cell line, RT112. The expression of MCL1 confers resistance to a range of apoptosis inducers, while the expression of DEDD led to resistance to TNFα-induced apoptosis. These observations identify
and
as genes that contribute to aggressive urothelial carcinoma. IMPLICATIONS: These studies identify
and
as genes that contribute to aggressive urothelial carcinomas.
Abstract
Background: Urothelial carcinoma (UC) is diagnosed in 72,570 patients annually. 20-30% of these patients have high grade advanced disease. These patients have had historically poor prognosis ...with 5-year survival rates of 33% and 6% in patients with regional and distant staged disease, respectively. Recent genomic analysis suggests that amplification of 1q23.3 may be associated with poor survival in patients with advanced UC. Using functional genomic screens, we aim to identify the genomic driver(s) of this association.
Methods: First, we created an arrayed shRNA screen with 79 shRNAs targeting 15 genes within this amplification. We studied these effects across 4 and 6 bladder cell lines with and without amplification of 1q23.3, respectively. We then performed secondary screens through the overexpression of these genes. This was performed in 2 UC cells lines without amplification of 1q23.3, RT-4 (grade 1 UC) and RT-112 (grade 2 UC) along with an immortalized bladder cell line, TRT-HU1. These secondary screens include assessment of morphology, proliferation, clonogenicity, anchorage independence by soft agar colony formation, migration and invasion by Boyden chambers, and in-vivo tumor growth.
Results: RIGER analysis of the arrayed shRNA screen identifies DEDD, F11R, ARHGAP30 and PVRL4 knockdown as inducing decreased proliferation (FDR <0.25) when comparing 1q23.3 amplified to non-amplified lines. Overexpression of those genes preliminarily shows: 1) ARHGAP30 overexpression changes the morphology from an epithelial to an amoeboid state in a subpopulation of both cancer cell lines. 2) DEDD overexpression confers a modest proliferative advantage in both UC cell lines. 3) No increased clonogenic potential or invasion/migration is observed when these genes are overexpressed. 4) DEDD and ARHGAP30 confer anchorage independence in RT-112 although this is not seen in RT-4 or TRT-HU1.
Conclusions: ARHGAP30 and DEDD are potential drivers within the amplification of 1q23.3 and possibly mediators of advanced urothelial carcinoma. Detailed biological mechanisms and cooperativity of these genes requires further investigation.
Citation Format: Andrew L. Hong, Markus Riester, Anna C. Schinzel, Amy Schlauch, Rosalyn M. Adam, David J. Kwiatkowski, Jonathan E. Rosenberg, William C. Hahn. ARHGAP30 and DEDD as potential genomic drivers of invasive urothelial carcinomas. abstract. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 3433. doi:10.1158/1538-7445.AM2014-3433
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