Faculty Bibliography

Patterns of discharge location may be evident based on the "sickness" profile of the patient. This study sought to evaluate the ability of the STTGMA tool, a validated mortality risk index for middle-aged and geriatric trauma patients, to predict discharge location in a cohort of low-energy elderly hip fracture patients, with successful discharge planning measured by readmission rates. Low-energy hip fracture patients aged 55 years and older were prospectively followed throughout their hospitalization. On initial evaluation in the Emergency Department, each patient's age, comorbidities, injury severity, and functional status were utilized to calculate a STTGMA score. Discharge location was recorded with the primary outcome measure of an unsuccessful discharge being readmission within 30 days. Patients were risk stratified into minimal-, low-, moderate-, and high-risk STTGMA cohorts. A p-value of <0.05 was considered significant for all statistical tests. 408 low-energy hip fractures were enrolled in the study with a mean age of 81.3±10.6 years. There were 214 (52.5%) intertrochanteric fractures, 167 (40.9%) femoral neck fractures, and 27 (6.6%) subtrochanteric femur fractures. There was no difference in readmission rates within STTGMA risk cohorts with respect to discharge location; however, among individual discharge locations there was significant variation in readmission rates when patients were risk stratified. Overall, STTGMA risk cohorts appeared to adequately risk-stratify readmission with 3.5% of minimal-risk patients experiencing readmission compared to 24.5% of moderate-risk patients. Specific cohorts deemed high-risk for readmission were adequately identified. The STTGMA tool allows for prediction of unfavorable discharge location in hip fracture patients. Based on observations made via the STTGMA tool, improvements in discharge planning can be undertaken to increase home discharge and to more closely track "high-risk" discharges to help prevent readmissions.

Introduction/UNASSIGNED:Frailty in elderly trauma populations has been correlated with an increased risk of morbidity and mortality. The Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) is a validated mortality risk score that evaluates 4 major physiologic criteria: age, comorbidities, vital signs, and anatomic injuries. The aim of this study was to investigate whether the addition of additional frailty variables to the STTGMA tool would improve risk stratification of a middle-aged and elderly trauma population. Methods/UNASSIGNED:A total of 1486 patients aged 55 years and older who met the American College of Surgeons Tier 1 to 3 criteria and/or who had orthopedic or neurosurgical traumatic consultations in the emergency department between September 2014 and September 2016 were included. The STTGMAORIGINAL and STTGMAFRAILTY scores were calculated. Additional "frailty variables" included preinjury assistive device use (disability), independent ambulatory status (functional independence), and albumin level (nutrition). The ability of the STTGMAORIGINAL and the STTGMAFRAILTY models to predict inpatient mortality was compared using area under the receiver operating characteristic curves (AUROCs). Results/UNASSIGNED:There were 23 high-energy inpatient mortalities (4.7%) and 20 low-energy inpatient mortalities (2.0%). When the STTGMAORIGINAL model was used, the AUROC in the high-energy and low-energy cohorts was 0.926 and 0.896, respectively. The AUROC for STTGMAFRAILTY for the high-energy and low-energy cohorts was 0.905 and 0.937, respectively. There was no significant difference in predictive capacity for inpatient mortality between STTGMAORIGINAL and STTGMAFRAILTY for both the high-energy and low-energy cohorts. Conclusion/UNASSIGNED:The original STTGMA tool accounts for important frailty factors including cognition and general health status. These variables combined with other major physiologic variables such as age and anatomic injuries appear to be sufficient to adequately and accurately quantify inpatient mortality risk. The addition of other common frailty factors that account for does not enhance the STTGMA tool's predictive capabilities.

BACKGROUND:Little is known about the time dependence of the failure rate of surgically repaired rotator cuffs. Retears are significant, as they are common and may lead to less satisfactory outcomes and additional operations. Their timing is critical foundational information for understanding failure mechanisms. However, this remains unclear. Currently, there exist a number of studies that have reported retear rates at specific time points. Combining data from these publications can reveal when cuffs retear, which will help inform expectations and guidelines for progression of activity after surgery. METHODS:PubMed, Medline, and Embase were searched for studies relating to rotator cuff repair. Abstracts and articles were evaluated on the basis of predefined inclusion and exclusion criteria. Data were extracted from those publications that satisfied all requirements, and regression analysis was performed. RESULTS:Thirteen articles were included in the final meta-analysis. Retear rates for medium tears increased for approximately 15 months and leveled off at approximately 20%. Retear rates for large tears progressed steadily for about 12 months and approached an upper limit of approximately 40%. Retear rates for massive tears ranged from 20% to 60%, but the distribution of retear rate over time for these cuff tears is not clear from these data. CONCLUSION/CONCLUSIONS:Retear rates for medium and large tears generally increase until at least 10-15 months after surgery, after which they are likely to level off. Retear rates for massive tears are variable and may follow a time course different from that of other tear sizes. Retear rates depend on size of the original tear.

OBJECTIVES: To assess the outcome of patients with hyperextension bicondylar tibial plateau fractures (HEBTPs) and those with other complex tibial plateau fractures. DESIGN: Retrospective cohort design. SETTING: Academic Medical Center. PATIENTS: A total of 84 patients were included in the study. There were 69 patients with 69 knees (82%) that had sustained non-HEBTPs and 15 patients with 15 knees (18%) that had HEBTPs. INTERVENTION: Surgical repair of bicondylar tibial plateau fracture. MAIN OUTCOME MEASURES: Clinical and functional outcomes included knee range of motion, postoperative alignment, numerical rating scale pain scores, and Short Musculoskeletal Functional Assessment (SMFA) scores at long-term follow-up. Complications were recorded for both cohorts including infection and posttraumatic osteoarthritis. RESULTS: There was no difference in knee range of motion at 1-year follow-up between hyperextension and nonhypertension patients. Patients with hyperextension mechanisms did however have higher functional (SMFA) scores and a trend of higher pain scores, indicating worsened functional outcomes and were more likely than their nonhyperextension mechanism counterparts to have associated soft-tissue damage and to develop posttraumatic osteoarthritis. CONCLUSIONS: Non-HEBTP and HEBTP fracture patients have similar outcomes in terms of range of motion at approximately 1 year of follow-up, however, differ significantly in terms of functional recovery and the types of complications associated with their injuries. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE: To compare the cost and outcomes of patients treated at orthopaedic teaching hospitals (OTHs) with those treated at nonteaching hospitals (NTHs). DESIGN: Retrospective study. SETTING: The Statewide Planning and Research Cooperative Systems (SPARCS) database, which includes all admissions to New York State hospitals from 2000-2011. PATIENTS/PARTICIPANTS: A total of 165,679 patients with isolated closed hip fracture 65 years of age and older met inclusion criteria. Of them, 57,279 were treated at OTH and 108,400 were treated at NTH. INTERVENTION: Admission for the management of a hip fracture. MAIN OUTCOME MEASURE: Cost, length of stay (LOS), and inpatient mortality. RESULTS: Univariate analysis shows that mean total hospital costs were higher at OTH ($16,576 +/- $17,514) versus NTH ($13,358 +/- $11,366) (P < 0.001); LOS was equivalent at OTH (8.0 +/- 9.0 days) versus NTH (8.0 +/- 7.6 days) (P = 0.904); and mortality was lower in OTH (3.4%) versus NTH (4.0%) (P < 0.001). In the multivariate total cost analysis, in addition to demographic differences, we identified total hospital beds and total ICU beds as significant confounding variables. Interestingly, when controlling for these patient and hospital factors, OTH designation was not a significant predictor of cost. In addition, multivariate analysis found that OTH status decreased LOS by 0.743 days (95% confidence interval: 0.632-0.854, P < 0.001) and mortality by 21% (odds ratio 0.794, 95% confidence interval: 0.733-0.859, P < 0.001), confirming the univariate trends. CONCLUSIONS: While OTH may seem to have higher hospital costs for operative hip fractures on cursory analysis, controlling for patient and hospital factors including hospital bed number negates this effect such that OTH has no additional cost compared with NTH. In addition, OTH status is associated with shorter LOS and lower in-hospital mortality. With the results of this study, health care systems and patients should feel confident that the quality of care at teaching hospitals is no less and potentially better than that at NTH with no added cost. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:Anterior cruciate ligament (ACL) injury rates are affected by frequency and level of competition, sex, and sport. To date, no study has sought to quantify sport-specific yearly risk for ACL tears in the high school (HS) athlete by sex and sport played. PURPOSE:To establish evidence-based incidence and yearly risk of ACL tears in HS athletes by sex for sports performed at the varsity level across the majority of US high schools. STUDY DESIGN:Meta-analysis. METHODS:PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were searched to identify all articles reporting ACL tears per athletic exposure in HS athletes. ACL injury incidence rates (IRs) by sex and sport were calculated via meta-analysis. State athletic association guidelines were used to determine the number of exposures per season to calculate yearly risk of ACL tears. RESULTS:The search recovered 3779 unique articles, of which 10 met our inclusion criteria, for a total of 700 ACL injuries in 11,239,029 exposures. The IR was 0.062 injuries per 1000 exposures (95% CI, 0.058-0.067). Although more injuries were recorded in males than females, females had a higher rate of injury per exposure (relative risk, 1.57; 95% CI, 1.35-1.82). Relative risk was highest in basketball (3.80; 95% CI, 2.53-5.85) and soccer (3.67; 95% CI, 2.61-5.27). While boys' football had the highest number of ACL injuries at 273, girls' soccer had the highest IR (0.148; 95% CI, 0.128-0.172). In girls, the highest injury risks per season were observed in soccer (1.11%; 95% CI, 0.96%-1.29%), basketball (0.88%; 95% CI, 0.71%-1.06%), and lacrosse (0.53%; 95% CI, 0.19%-1.15%). In comparison, the highest risks for boys were observed in football (0.80%; 95% CI, 0.71%-0.91%), lacrosse (0.44%; 95% CI, 0.18%-0.90%), and soccer (0.30%; 95% CI, 0.22%-0.41%). CONCLUSION:There is an approximately 1.6-fold greater rate of ACL tears per athletic exposure in HS female athletes than males. However, there is significant risk in both sexes, particularly in high-risk sports such as soccer, football, basketball, and lacrosse. Knowledge of sport-specific risk is essential for future injury reduction programs, parent-athlete decision making, and accurate physician counseling.

The previously constructed MSP (manganese stabilizing protein-psbO gene product)-free mutant of Synechococcus PCC7942 (Bockholt R, Masepohl B and Pistorius E K (1991) FEBS Lett 294: 59-63) and a newly constructed MSP-free mutant of Synechocystis PCC6803 were investigated with respect to the inactivation of the water-oxidizing enzyme during dark incubation. O2 evolution in the MSP-free mutant cells, when measured with a sequence of short saturating light flashes, was practically zero after an extended dark adaptation, while O2 evolution in the corresponding wild type cells remained nearly constant. It could be shown that this inactivation could be reversed by photoactivation. With isolated thylakoid membranes from the MSP-free mutant of PCC7942, it could be demonstrated that photoactivation required illumination in the presence of Mn(2+) and Ca(2+), while Cl(-) addition was not required under our experimental conditions. Moreover, an extended analysis of the kinetic properties of the water-oxidizing enzyme (kinetics of the S3→(S4)→S0 transition, S-state distribution, deactivation kinetics) in wild type and mutant cells of Synechococcus PCC7942 and Synechocystis PCC6803 was performed, and the events possibly leading to the reversible inactivation of the water-oxidizing enzyme in the mutant cells are discussed. We could also show that the water-oxidizing enzyme in the MSP-free mutant cells is more sensitive to inhibition by added NH4Cl-suggesting that NH3 might be a physiological inhibitor of the water oxidizing enzyme in the absence of MSP.