Faculty Bibliography

OBJECTIVES/OBJECTIVE:To determine whether a validated trauma triage tool can identify which middle-aged and geriatric trauma patients with tibial shaft and plateau fractures are at risk for costly admissions and poorer hospital quality measures. DESIGN/METHODS:Prospective cohort study. SETTING/METHODS:Level 1 trauma center. PATIENTS/PARTICIPANTS/METHODS:64 patients over the age of 55 hospitalized with isolated tibial shaft or plateau fractures. INTERVENTION/METHODS:Patients with either isolated tibial plateau fractures or tibial shaft fractures over a three year period were prospectively enrolled in an orthopedic trauma registry. Demographic information, injury severity, and comorbidities were assessed and incorporated into the STTGMA score, a validated trauma triage score that calculates inpatient mortality risk upon admission. Patients were then grouped into tertiles based on their STTGMA score. MAIN OUTCOME MEASUREMENTS/METHODS:Length of stay, complications, discharge location, and direct variable costs. RESULTS:64 patients met inclusion criteria. 33 (51.6%) patients presented with tibial plateau fractures and 31 (48.4%) with tibial shaft fractures. The mean age was 66.7 ± 10.2 years. Mean length of stay was significantly different between risk groups with a mean of 6.8 ± 4 days (p<0.001). While 19 (90.5%) of minimal risk patients were discharged home, only 7 (33.3%) and 5 (22.7%) of moderate and high-risk patients were discharged home, respectively (p<0.001). Higher risk patients experienced a significantly greater number of complications during hospitalization but had no differences in the need for ICU level care (p=0.027 and p=0.344, respectively). The total cost difference between the lowest and highest risk group was nearly 50% ($14070 ± 8056 vs $25147 ± 14471, mean difference $11077; p=0.022). CONCLUSION/CONCLUSIONS:Application of the STTGMA triage tool allows for prediction of key hospital quality measures and cost of hospitalization that can improve clinical decision-making. LEVEL OF EVIDENCE/METHODS:Prognostic Level III.

The SARS-COV-2 (COVID-19) pandemic has placed unprecedented challenges on the health care system in the United States with New York City at its epicenter. By the end of the 8 week (4/23/2020) since the virus's emergence in New York City, there have been 142,432 confirmed COVID-19 cases and 10,977 deaths attributed to complications from COVID-19-related illnesses. Secondary to policies enacted by the New York State government to limit spread of the virus, Orthopedic Surgery departments at hospitals around the area have witnessed an abrupt change in clinical demands. At a local level one trauma hospital in Queens, New York, Orthopedic Surgery elective cases have been cancelled, trauma consult volume has experienced a sharp decline, and both residents and attendings have been repurposed to meet the new clinical demands of this medical crisis. Our own orthopedic surgery service has adopted care for patients normally admitted to an internal medicine service in a novel Ortho-Medical COVID-19 management team. We prepared this primer to make our experience with caring for COVID-19 patents available as a reference for other surgical subspecialty services preparing to adjust the clinical focus of their hospital teams during this or future pandemics. LEVEL OF EVIDENCE:: Level V.

Lateral compression type 1 pelvic fractures comprise a spectrum of injuries of varying stability. The clinician should be cognizant of signs and symptoms of instability including complete sacral fractures, bilateral ramus fractures, displacement greater than 1 cm, high-energy mechanism, and inability to bear weight. Management of these injuries is controversial, but the clinician should consider examination under anesthesia and potentially surgical stabilization.

BACKGROUND:Chemotherapy and targeted therapies have made important strides in cancer treatment yet they often fail and new therapies are still needed. Here, we employed a phenotypic screen to identify and analyze the mechanism of action of novel small molecules that interfere with critical pathways involved in tumor cell growth, using chemoresistant A375 melanoma cells as a model. METHODS:Cell culture studies were performed in ATCC-recommended media. Compounds, and compound libraries were obtained from Boston University or purchased commercially. Effects on A375 cell viability, proliferation and morphology were determined by Celigo Image Cytometer and viability staining. Anticancer activity of the lead compound was tested in a xenograft nude mouse model. Signaling and cell death pathways were analyzed by SDS-PAGE and immunoblotting, and/or fluorescence microscopy. RESULTS:After evaluating 4477 compounds, one hit compound CB533 was identified that caused significant reduction of A375 cell growth. CB533 is an unexplored 1,4-naphthoquinone (NQ) derivative which unlike 1,4-NQ, induced rapid cell death without generating reactive oxygen species (ROS). Structure-activity relationship analysis showed that a pyrrolidine in the 1,4-NQ nucleus in lead compound Pyr-1 yielded optimal activity. CB533 and Pyr-1 had growth-suppressing effects on a large variety of chemotherapy-resistant cancer cell lines in the nano to picomolar range. Pyr-1 also significantly reduced growth of MDA-MB-231 breast cancer cells in nude mice. Pyr-1 rapidly induced activation of major stress pathways and autophagy, which was efficiently blocked by ERK, and somewhat by PI3K inhibitors. CONCLUSION/CONCLUSIONS:CB533 and lead Pyr-1 represent novel broad-spectrum, anticancer compounds that are up to 1000-fold more potent than plumbagin, a natural 1,4-NQ with known anticancer activity. Since the growth suppression activities of CB533 and Pyr-1 are unaffected by the chemotherapy resistance of cancer cells, these compounds have promising therapeutic potential. The pyrrolidine in the 3 position of the 1,4-NQ nucleus of Pyr-1 is a critical component of the pharmacophore. Pyr-1-induced cellular stress was mediated by an ERK, and to a lesser extent by an AKT-dependent pathway without involving apoptosis. Our data suggest that Pyr-1 derives its greatly enhanced antitumor activity via mimicking ROS-induced stress signaling without generating ROS, and likely committing cells to autophagy.

OBJECTIVES/OBJECTIVE:To compare the efficacy of an infraclavicular single-shot nerve block to a continuous infusion through an OnQ infusion pump for rebound pain (between 12 and 24 hours postoperatively) and postoperative narcotic analgesia requirements in distal radius fractures. DESIGN/METHODS:Prospective randomized control trial. SETTINGS/METHODS:Performed at 2 hospitals affiliated with a large urban academic medical center. PATIENTS/METHODS:Fifty patients undergoing operative fixation of distal radius fractures (OTA/AO type 23B/C). INTERVENTION/METHODS:Patients were randomized to receive either an infraclavicular block as a single shot (SSB group) or a continuous infusion through an OnQ pump (OnQ group). MAIN OUTCOME MEASURES/METHODS:Visual analog scale (0-10) pain levels and amount of pain medication taken. RESULTS:At all time points after discharge, mean postoperative pain scores were lower in the OnQ group versus the SSB group but did not reach statistical significance. At 12 hours postoperatively, the SSB group and OnQ group pain scores, respectively, were 5.2 and 4.1 (P = 0.1615). At 24 hours, the pain scores for the SSB and OnQ group, respectively, were 5.4 and 4.8 (P = 0.1918). At these same time points, the Percocet taken were the same at 1.3 and 2.3 (P = 0.8328 and 0.8617). Overall 5 of 24 patients in the OnQ group had pump malfunctions with 4 being removed before 48 hours. CONCLUSION/CONCLUSIONS:OnQ pump is not associated with statistically improved postoperative pain control compared with a single nerve block for distal radius fractures and did not address rebound pain. LEVEL OF EVIDENCE/METHODS:Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Anterior cruciate ligament (ACL) injuries are among the most commonly studied orthopaedic injuries. Despite having an excellent prognosis, complications do occur. The timely recognition and management of complications is imperative to ensure the success of reconstruction. Avoiding such complications requires thorough preoperative planning, proficient technical skills to properly manage intraoperative complications, and an extensive knowledge of possible postoperative complications.

Although studies have revealed high readability levels of orthopedic patient education materials, no study has evaluated sports medicine-related patient education materials. We conducted a study to assess the readability of sports medicine-related patient education materials from the American Academy of Orthopaedic Surgeons (AAOS) and the American Orthopaedic Society for Sports Medicine (AOSSM). All sports medicine patient education articles available online in 2012 from the AAOS and the AOSSM, including the Stop Sports Injuries Campaign (STOP), were identified, and their readability was assessed with the Flesch-Kinkaid (FK) readability test. Mean overall FK grade level of the 170 articles reviewed (104 from AAOS, 36 from AOSSM, 30 from STOP) was 10.2. Mean FK levels for the 3 sources were 9.5 (AAOS), 11.0 (AOSSM), and 11.5 (STOP) (P = .16). Fifteen (8.8%) of the 170 articles had a readability level at or below eighth grade (average reading level of US adults); only 2 (1.2%) of the 170 articles were at or below the recommended sixth-grade level. The majority of sports medicine-related patient education materials from AAOS and AOSSM had reading levels higher than recommended, indicating that the majority of the patient population may find it difficult to comprehend these articles.