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Sickle cell disease (SCD) is a hemoglobinopathy that commonly has musculoskeletal effects including osteonecrosis of major joints (most often the hip) and medullary infarcts with resultant pain, functional limitations, and decreased quality of life. Patients with SCD may require surgical intervention, including total hip arthroplasty, frequently at a young age. The underlying pathologic process of SCD creates unique medical and surgical challenges that place these patients at increased risk of complications. This necessitates a multidisciplinary approach for providing surgical care to patients with SCD.

Determining the clinical effort associated with preparing for revision total hip and knee arthroplasty is necessary to maintain the appropriate work relative value unit rating. We have investigated the work done by the orthopedic surgical team in the days and weeks prior to revision hip and knee arthroplasty using a count of time by team members in the electronic medical record (EMR).EMR audit logs were generated, and preoperative work (POW) was calculated for members of the surgical team for 200 sequential revision cases. Independent samples t-tests were conducted to compare total POW for procedure, age, gender, insurance, and health literacy; significance threshold was set at P = .05.POW was 97.7 minutes (standard deviation [SD] 53.1). Surgeon POW accounted for 10.5 minutes (SD 9.3), nurses for 29.9 minutes (SD 34.2), mid-level providers for 22.1 minutes (SD 17.0), and office technicians for 34.1 minutes (SD 35.2). There was no difference in total POW based on procedure (hip vs knee), age, gender, insurance type, or health literacy.Revision arthroplasty requires substantial preoperative preparation from the surgical team. Most of this is by nurses, mid-level providers, and office staff. This does not seem to be different for hip or knee revisions or by age and gender. EMR audit logs capture the bare minimum POW required to prepare a patient for revision arthroplasty.

The voluntary hip and femur fracture Bundled Payments for Care Improvement Advanced (BCPI-A) includes Diagnosis Related Groups (DRG) 480, 481, and 482, which include diverse and medically complex patients undergoing urgent inpatient surgery without optimization. Concern exists that this bundle is financially unfavorable for hospitals, and this study aimed to identify the costliest services.We retrospectively reviewed a 12-month cohort of 32 consecutive patients in the DRG 480-482 bundle at our academic tertiary referral center. Cost of discharge disposition, readmission, and other variables were analyzed for all patients in the 90-day bundle.Overall, a net financial gain averaging $2,028 per patient (range -$52,128 to +$30,199) was seen. Discharge to facilities (n = 19) resulted in higher costs than discharge to home (n = 11, P.0001). Use of inpatient rehabilitation (n = 6) averaged a loss of $11,028 per patient and use of skilled nursing facilities (n = 15) averaged a loss of $7,250 per patient, compared to a gain of $15,011 for patients discharged home (n = 11). Episodes with readmission (n = 6) averaged a loss of only $1,390. Total index admission costs averaged $12,489 ± $2,235 per patient (range $9,329-$18,884) while post-inpatient cost averaged $30,150 per patient (range $4,803 - $77,768).The BPCI-A hip and femur fracture bundle has a wide variability in costs, with the largest component in the post-acute care phase. Discharge home is favorable in the bundle while discharge to post-acute facilities leads to net losses. Institutions in this bundle need to develop multi-disciplinary teams to promote safe discharge home.

BACKGROUND: Many patients have unmet social needs that may affect their health care utilization and outcomes. We sought to examine a program to determine the types of social needs facing arthroplasty patients and methods used to address these needs. METHODS: We conducted a pilot, retrospective review of our integrated social needs program for total joint arthroplasty (TJA) patients. A 16-question needs assessment was instituted as part of our perioperative protocol between February 1, 2020, to October 1, 2020. We examined the types of social needs in 250 primary TJA patients and a resolution method. We evaluated associations between social needs and demographics and Area Deprivation Index (ADI). Outcome measures were also evaluated, including readmissions, discharge date, and outcome score changes. RESULTS: Forty-four (17.6%) patients had a social need. Social needs frequency increased in non-White patients (P ≤ .0001), non-English speakers (P = .0304), younger patients (P = .001), nonmarried patients (P = .0006), unemployed patients (P = .0189), and patients with less health literacy (P = .0215). ADI scores were positively associated with social needs at the national (P = .0006) and state levels (P = .0004). Overall, 75.9% of needs centered around utility payments, employment, prescription costs, education, and transportation. In addition, 64% of the identified needs were resolved through outside referrals. Ninety-day readmissions were significantly higher in patients with social needs (P = .0087). DISCUSSION: Overall, 17.6% of patients in our state have social needs before TJA. Factors increasing the risk of social needs include younger age, minority race, single or divorced marital status, unemployment, low health literacy, and higher ADI. The 90-day readmission rate was significantly higher in patients with social needs.

Crimean-Congo Hemorrhagic Fever Virus (CCHFV) is a tick-borne virus that causes severe hemorrhagic disease in humans. There is a great need for effective vaccines and therapeutics against CCHFV for humans, as none are currently internationally approved. Recently, a monoclonal antibody against the GP38 glycoprotein protected mice against lethal CCHFV challenge. To show that GP38 is required and sufficient for protection against CCHFV, we used three inactivated rhabdoviral-based CCHFV-M vaccines, with or without GP38 in the presence or absence of the other CCHFV glycoproteins. All three vaccines elicited strong antibody responses against the respective CCHFV glycoproteins. However, only vaccines containing GP38 showed protection against CCHFV challenge in mice; vaccines without GP38 were not protective. The results of this study establish the need for GP38 in vaccines targeting CCHFV-M and demonstrate the efficacy of a CCHFV vaccine candidate based on an established vector platform.

The number of annual total joint arthroplasties (TJA) is increasing. Periprosthetic joint infections (PJI) occur when there is infection involving the prosthesis and surrounding tissue, which has the potential to develop into sepsis if left untreated. Sepsis in patients who have undergone TJA is life threatening and requires urgent treatment. If sepsis is due to PJI, the focus should be on early intravenous antibiotics with aspiration as soon as possible to diagnose the infection. Patients who develop sepsis after surgery for PJI are particularly at high risk for mortality and need to be treated in the intensive care unit.

Data sharing: The PHOSP-COVID study protocol, consent form, definition, and derivation of clinical characteristics and outcomes, training materials, regulatory documents, information about requests for data access, and other relevant study materials are available online. UK Biobank information can be released once necessary approvals have been obtained. Other data (eg, the R code and protocol) will be made available on reasonable request to the corresponding author. Copyright © 2023 The Author(s). Background: Sleep disturbance is common following hospital admission both for COVID-19 and other causes. The clinical associations of this for recovery after hospital admission are poorly understood despite sleep disturbance contributing to morbidity in other scenarios. We aimed to investigate the prevalence and nature of sleep disturbance after discharge following hospital admission for COVID-19 and to assess whether this was associated with dyspnoea. Methods: CircCOVID was a prospective multicentre cohort substudy designed to investigate the effects of circadian disruption and sleep disturbance on recovery after COVID-19 in a cohort of participants aged 18 years or older, admitted to hospital for COVID-19 in the UK, and discharged between March, 2020, and October, 2021. Participants were recruited from the Post-hospitalisation COVID-19 study (PHOSP-COVID). Follow-up data were collected at two timepoints: an early time point 2–7 months after hospital discharge and a later time point 10–14 months after hospital discharge. Sleep quality was assessed subjectively using the Pittsburgh Sleep Quality Index questionnaire and a numerical rating scale. Sleep quality was also assessed with an accelerometer worn on the wrist (actigraphy) for 14 days. Participants were also clinically phenotyped, including assessment of symptoms (ie, anxiety [Generalised Anxiety Disorder 7-item scale questionnaire], muscle function [SARC-F questionnaire], dyspnoea [Dyspnoea-12 questionnaire] and measurement of lung function), at the early timepoint after discharge. Actigraphy results were also compared to a matched UK Biobank cohort (non-hospitalised individuals and recently hospitalised individuals). Multivariable linear regression was used to define associations of sleep disturbance with the primary outcome of breathlessness and the other clinical symptoms. PHOSP-COVID is registered on the ISRCTN Registry (ISRCTN10980107). Findings: 2320 of 2468 participants in the PHOSP-COVID study attended an early timepoint research visit a median of 5 months (IQR 4–6) following discharge from 83 hospitals in the UK. Data for sleep quality were assessed by subjective measures (the Pittsburgh Sleep Quality Index questionnaire and the numerical rating scale) for 638 participants at the early time point. Sleep quality was also assessed using device-based measures (actigraphy) a median of 7 months (IQR 5–8 months) after discharge from hospital for 729 participants. After discharge from hospital, the majority (396 [62%] of 638) of participants who had been admitted to hospital for COVID-19 reported poor sleep quality in response to the Pittsburgh Sleep Quality Index questionnaire. A comparable proportion (338 [53%] of 638) of participants felt their sleep quality had deteriorated following discharge after COVID-19 admission, as assessed by the numerical rating scale. Device-based measurements were compared to an age-matched, sex-matched, BMI-matched, and time from discharge-matched UK Biobank cohort who had recently been admitted to hospital. Compared to the recently hospitalised matched UK Biobank cohort, participants in our study slept on average 65 min (95% CI 59 to 71) longer, had a lower sleep regularity index (–19%; 95% CI –20 to –16), and a lower sleep efficiency (3·83 percentage points; 95% CI 3·40 to 4·26). Similar results were obtained when comparisons were made with the non-hospitalised UK Biobank cohort. Overall sleep quality (unadjusted effect estimate 3·94; 95% CI 2·78 to 5·10), deterioration in sleep quality following hospital admission (3·00; 1·82 to 4·28), and sleep regularity (4·38; 2·10 to 6·65) were associated with higher dyspnoea scores. Poor sleep quality, deterioration in sleep quality, and sleep regularity were also associated with impaired lung function, as assessed by forced vital capacity. Depending on the sleep metric, anxiety mediated 18–39% of the effect of sleep disturbance on dyspnoea, while muscle weakness mediated 27–41% of this effect. Interpretation: Sleep disturbance following hospital admission for COVID-19 is associated with dyspnoea, anxiety, and muscle weakness. Due to the association with multiple symptoms, targeting sleep disturbance might be beneficial in treating the post-COVID-19 condition. Funding: UK Research and Innovation, National Institute for Health Research, and Engineering and Physical Sciences Research Council. UK Research and Innovation, National Institute for Health Research, and Engineering and Physical Sciences Research Council.

The coronavirus disease 2019 (COVID-19) pandemic impacted the inpatient experience before and after total joint arthroplasty (TJA). This study aimed to examine how these changes affected patient satisfaction following TJA as recorded by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) postdischarge surveys and comments at 2 large academic institutions. A retrospective review identified patients who completed HCAHPS surveys following primary and revision TJA at 2 academic institutions: 1 in a predominately rural southern state (Institution A) and 1 in a northeastern metropolitan city (Institution B). Patients were grouped by discharge date: pre–COVID-19 (April 1, 2019, to October 31, 2019) or COVID-19 affected (April 1, 2020, to October 31, 2020). Differences in demographics, survey responses, and comment sentiments and themes were collected and evaluated. The number of HCAHPS surveys completed increased between periods at Institution A but decreased at Institution B (Institution A, 61 vs 103; Institution B, 524 vs 296). Rates of top-box survey responses remained the same across the 2 periods. The number of comments decreased at Institution B (1977 vs 1012) but increased at Institution A (55 vs 88). During the COVID-19–affected period, there was a significant increase in the negative comment rate from Institution B (11.6% vs 14.8%, P =.013) and a significant decrease in the positive comment rate from Institution A (70.9% vs 44.3%, P Orthopedics . 2023;46(2):e105–e110.]

During the Coronavirus Disease 2019 (COVID-19) pandemic, states implemented social distancing guidelines. This study examines the effect of the severity of lockdown orders on orthopaedic trauma volume. Two institutions, one in a state with strict stay home (SH) orders and one in a state with lax social distancing (SD) orders, were examined. Surgical case counts, total orthopaedic case counts, orthopaedic trauma case counts, institution trauma activations, and mechanism of injury data were collected and compared to control periods. For SH versus SD, total surgical cases decreased 48.6% vs. 62%; orthopaedic cases decreased 51.8% vs. 62%, and orthopaedic trauma cases decreased 34% v. 0%. Orthopaedic trauma cases comprised more of both institutions' total cases. Total surgical cases decreased at both SH and SD, but orthopaedic trauma cases did not decrease at SD. More strict social distancing orders correlate with greater reduction in orthopaedic trauma cases. (Journal of Surgical Orthopaedic Advances 31(4):222-225, 2022).

Periprosthetic fracture occurring during or after total knee arthroplasty is a rare injury. Literature concerning periprosthetic tibial factures is sparse, and there is limited guidance for evidence-based management. This review aims to provide readers with an overview of the epidemiology, risk factors, and classification of these fractures. Management includes nonoperative treatment of nondisplaced fractures, fixation for those with stable implants, and revision for those with loose implants.

Background This study examines cobalt levels and pseudotumor characteristics in a non-recalled modular femoral prosthesis. We sought to determine relationships between serum cobalt levels and pseudotumors following modular and metal-on-metal (MoM) total hip arthroplasty (THA), the location and size of pseudotumors, and changes to pseudotumor grade over time. Methods We retrospectively evaluated a cohort of 190 primary THAs implanted with a dual-modular femoral stem by one surgeon from 2005 to 2013. One hundred seventeen THAs used a cobalt-chromium modular neck (CoCrMN) component and non-MoM articulation, 63 THAs had a titanium neck component and MoM articulation, and 10 had a titanium neck component and polyethylene liner. Serum ion levels were recorded for all patients. Pseudotumor grade and location were measured by musculoskeletal-trained radiologists. Results Cobalt levels did not correlate to time after index arthroplasty. In the CoCrMN group, cobalt levels were elevated in 11 of 19 (57.9%) patients with pseudotumor compared to 14 of 19 (73.7%) in the MoM group. Pseudotumors were more often located lateral to the hip joint in the CoCrMN group compared to anteromedial following MoM arthroplasty. In CoCrMN THAs, pseudotumors were visualized in 12 of 51 (23.5%) initial MARS MRIs within 40 months compared to 5 of 66 (7.6%) performed later (P = .02). Conclusion Pseudotumor characteristics differ between patients with CoCrMN designs vs those with an MoM articulation. Normal serum cobalt levels did not exclude the presence of a pseudotumor and routine MARS MRI should be included in follow-up of patients with this CoCrMN prostheses.

Data sharing statement This is an Open Access article under the CC BY 4.0 license The ISARIC4C protocol, data sharing and publication policy are available at https://isaric4c.net. ISARIC4C's Independent Data and Material Access Committee welcomes applications for access to data and materials (https://isaric4c.net). The PHOSP-COVID protocol, consent form, definition and derivation of clinical characteristics and outcomes, training materials, regulatory documents, information about requests for data access, and other relevant study materials are available online: https://phosp.org/resource/. Access to these materials can be granted by contacting phosp@leicester.ac.uk and Phospcontracts@leicester.ac.uk. All data used in this study is available within ODAP and accessible under reasonable request. Data access criteria and information about how to request access is available online: https://phosp.org/resource/. If criteria are met and a request is made, access can be gained by signing the eDRIS user agreement. Supplementary data are available online at https://www.thelancet.com/journals/ebiom/article/PIIS2352-3964(22)00584-9/fulltext#supplementaryMaterial . Copyright © 2022 The Author(s). Background: Most studies of immunity to SARS-CoV-2 focus on circulating antibody, giving limited insights into mucosal defences that prevent viral replication and onward transmission. We studied nasal and plasma antibody responses one year after hospitalisation for COVID-19, including a period when SARS-CoV-2 vaccination was introduced. Methods: In this follow up study, plasma and nasosorption samples were prospectively collected from 446 adults hospitalised for COVID-19 between February 2020 and March 2021 via the ISARIC4C and PHOSP-COVID consortia. IgA and IgG responses to NP and S of ancestral SARS-CoV-2, Delta and Omicron (BA.1) variants were measured by electrochemiluminescence and compared with plasma neutralisation data. Findings: Strong and consistent nasal anti-NP and anti-S IgA responses were demonstrated, which remained elevated for nine months (p < 0.0001). Nasal and plasma anti-S IgG remained elevated for at least 12 months (p < 0.0001) with plasma neutralising titres that were raised against all variants compared to controls (p < 0.0001). Of 323 with complete data, 307 were vaccinated between 6 and 12 months; coinciding with rises in nasal and plasma IgA and IgG anti-S titres for all SARS-CoV-2 variants, although the change in nasal IgA was minimal (1.46-fold change after 10 months, p = 0.011) and the median remained below the positive threshold determined by pre-pandemic controls. Samples 12 months after admission showed no association between nasal IgA and plasma IgG anti-S responses (R = 0.05, p = 0.18), indicating that nasal IgA responses are distinct from those in plasma and minimally boosted by vaccination. Interpretation: The decline in nasal IgA responses 9 months after infection and minimal impact of subsequent vaccination may explain the lack of long-lasting nasal defence against reinfection and the limited effects of vaccination on transmission. These findings highlight the need to develop vaccines that enhance nasal immunity. Funding: This study has been supported by ISARIC4C and PHOSP-COVID consortia. ISARIC4C is supported by grants from the National Institute for Health and Care Research and the Medical Research Council. Liverpool Experimental Cancer Medicine Centre provided infrastructure support for this research. The PHOSP-COVD study is jointly funded by UK Research and Innovation and National Institute of Health and Care Research. The funders were not involved in the study design, interpretation of data or the writing of this manuscript. This work is supported by the following grants: The PHOSP-COVD study is jointly funded by UK Research and Innovation and National Institute for Health and Care Research (grant references: MR/V027859/1 and COV0319). ISARIC4C is supported by grants from the National Institute for Health and Care Research (award CO-CIN-01) and the Medical Research Council (grant MC_PC_19059) Liverpool Experimental Cancer Medicine Centre provided infrastructure support for this research (grant reference: C18616/A25153). Other grants which have supported this work include: the UK Coronavirus Immunology Consortium [funder reference:1257927], the Imperial Biomedical Research Centre (NIHR Imperial BRC, grant IS-BRC-1215-20013), the Health Protection Research Unit (HPRU) in Respiratory Infections at Imperial College London and NIHR HPRU in Emerging and Zoonotic Infections at University of Liverpool, both in partnership with Public Health England, [NIHR award 200907], Wellcome Trust and Department for International Development [215091/Z/18/Z], Health Data Research UK (HDR UK) [grant code: 2021.0155], Medical Research Council [grant code: MC_UU_12014/12], and NIHR Clinical Research Network for providing infrastructure support for this research. FL is supported by an MRC clinical training fellowship [award MR/W000970/1]. LPH is supported by Oxford NIHR Biomedical Research Centre. AART is supported by a BHF Intermediate Clinical Fellowship (FS/18/13/33281). SLRJ receives support from UKRI, GCRF, Rosetrees Trust, BHIVA, EDCTP, Globvac. JDC has grants from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Gilead Sciences, Grifols, Novartis and Insmed. RAE holds a NIHR Clinician Scientist Fellowship (CS-2016-16-020). AH is currently supported by UK Research and Innovation. NIHR and NIHR Manchester BRC. BR receives support from BHF Oxford Centre of Research Excellence, NIHR Oxford BRC and MRC. SJD is funded by an NIHR Global Research Professorship [NIHR300791]. DW is supported by an NIHR Advanced Fellowship. AH has received support from MRC and the Coronavirus Immunology Consortium (MR/V028448/1). LVW has received support from UKRI, GSK/Asthma + Lung UK and NIHR for this study. MGS has received support from NIHR UK, MRC UK and Health Protection Research Unit in Emerging & Zoonotic Infections, University of Liverpool. JKB is supported by the Wellcome Trust (223164/Z/21/Z) and UKRI (MC_PC_20004, MC_PC_19025, MC_PC_1905, MRNO2995X/1, and MC_PC_20029). PJMO is supported by a NIHR Senior Investigator Award [award 201385]. LT is supported by the Wellcome Trust [clinical career development fellowship grant number 205228/Z/16/Z], the Centre of Excellence in Infectious Diseases Research (CEIDR) and the Alder Hey Charity.

Crimean-Congo hemorrhagic fever (CCHF) is a medically relevant tick-borne viral disease caused by the Bunyavirus, Crimean-Congo hemorrhagic fever virus (CCHFV). CCHFV is endemic to Asia, the Middle East, South-eastern Europe, and Africa and is transmitted in enzootic cycles among ticks, mammals, and birds. Human infections are mostly subclinical or limited to mild febrile illness. Severe disease may develop, resulting in multi-organ failure, hemorrhagic manifestations, and case-fatality rates up to 30%. Despite the widespread distribution and life-threatening potential, no treatments have been approved for CCHF. Antiviral inhibitory peptides, which antagonize viral entry, are licensed for clinical use in certain viral infections and have been experimentally designed against human pathogenic bunyaviruses, with in vitro and in vivo efficacies. We designed inhibitory peptides against CCHFV with and without conjugation to various polyethylene glycol and sterol groups. These additions have been shown to enhance both cellular uptake and antiviral activity. Peptides were evaluated against pseudotyped and wild-type CCHFV via neutralization tests, Nairovirus fusion assays, and cytotoxicity profiling. Four peptides neutralized CCHFV with two of these peptides shown to inhibit viral fusion. This work represents the development of experimental countermeasures for CCHF, describes a nairovirus immunofluorescence fusion assay, and illustrates the utility of pseudotyped CCHFV for the screening of entry antagonists at low containment settings for CCHF.

Flexion instability (FI) is one of the leading causes of knee pain and revision surgery. Generally, the biomechanical etiology is considered to be a larger flexion than extension gap. This may be due to mismatch of components sizes to the bone or malalignment. Other factors such as muscle weakness may also play a role, and the diagnosis of FI after total knee arthroplasty (TKA) relies on a combination of patient's complaints during stair descent or walking and physical examination findings. Our study examines the role of implant positioning and sizes in the diagnosis of FI. A retrospective review of 20 subjects without perceived FI and 13 patients diagnosed with FI after TKA was conducted. Knee injury and osteoarthritis outcome scores (KOOS) were documented, and postoperative radiographs were examined. Measurements including included tibial slope, condylar offset, femoral joint line elevation along with surrogate soft-tissue measures for girth and were compared between groups. The FI group was found to have a significantly lower KOOS score compared with the non-FI group (55.6 vs. 73.5; p = 0.009) as well as smaller soft-tissue measurements over the pretubercle region (6.0 mm vs. 10.6 mm; p = 0.007). Tibial slope, condylar offset ratios, and femoral joint line elevation were not significantly different between the FI and non-FI groups. We noted a significant difference in tibial slope in posterior-stabilized implants in subjects with and without FI (6.4° vs. 1.5°; p = 0.003). Radiographic measurements consistent with malalignment were not indicative of FI. X-ray measurements alone are not sufficient to conclude FI as patient symptoms, and clinical examinations remain the key indicators for diagnosis. Radiographic findings may aid in surgeon determination of an underlying cause for an already identified FI situation and help in planning revision surgery.

Patients who have total knee arthroplasty (TKA) likely suffer from decreased postural stability because of postoperative changes in musculoskeletal structure and loss of proprioception. The purpose of this experimental biomechanical study was to determine if patients who have TKA improve their dynamic postural control during walking after TKA as compared with before TKA. The secondary purpose was to assess changes in postural control between post-TKA patients and healthy controls.Twenty-three patients who had primary knee osteoarthritis scheduled to undergo unilateral or bilateral TKA were prospectively enrolled. Each patient was tested at 3 months, 6 months, and 12 months after TKA. Ten healthy controls matched for age, sex, and body mass index were selected from a database of previous healthy volunteers without knee osteoarthritis. Ten Vicon cameras and four AMTI force platforms were used to collect the marker and center of pressure (COP) data while participants performed gait.Initial improvement in the double stance ratio was found by 6 months after TKA compared with before TKA. Patients showed improved postural control as evidenced by a faster mediolateral COP velocity and decreased double stance ratio at 12-month post-TKA compared with pre-TKA (P.05). However, patients who underwent TKA exhibited limited ability to maintain consistent COP movement during walking with increased variability in COP parameters as compared with controls (P.05).Patients exhibited improvement in dynamic postural control after TKA with time, but had higher variability in COP parameters during gait than controls. It is possible that therapy aimed to improve proprioceptive balance after TKA may improve dynamic postural control.

Background The alpha-defensin test known as Synovaure has been very effective in diagnosis of prosthetic joint infections (PJIs). Being able to easily and accurately differentiate septic and inflammatory arthropathies in native joints would improve diagnostic workup and management. We tested the ability of an alpha-defensin test to distinguish septic from inflammatory or crystalline arthropathy in the native knee. Methods 40 native knee joint fluid specimens were tested with cell count, fluid analysis, and culture and alpha-defensin testing. We determined the sensitivity and specificity of the alpha-defensin test using culture-positive fluid as the gold standard for septic arthropathy and positive crystals as the gold standard for crystalline arthropathy. Results The Synovasure PJI test had 100% specificity for septic arthritis coupled with a 28% false-positive rate when applied to native knee aspirations. False-positive rate was 5.3 times higher in patients with crystals found in the joint fluid. Conclusion Alpha-defensin testing, in the form of the Synovasure PJI test, has a high-false-positive rate when used to distinguish septic and inflammatory arthritis in the native knee joint. Future work will need to determine the sensitivity and specificity of the newer native joint panel. Clinicians should be cognizant of the specific alpha-defensin test used when sampling native knee synovial fluid.

BACKGROUND: In order to achieve rapid recovery total joint arthroplasty, surgeons and their teams are spending more time in the weeks before surgery to prepare patients. This study aims to quantify total knee and hip prearthroplasty work using retrospective electronic medical record (EMR) activity audit log analysis. METHODS: EMR activity in 100 elective knee and 100 elective hip arthroplasty cases was performed using audit logs. Each mouse click and action in the EMR was recorded. The time between mouse clicks was calculated and summed for each member of the clinical team. Descriptive statistics and independent samples t-tests were conducted to quantify and compare total preoperative work (POW) between groups defined by gender, procedure, age, insurance type, or health literacy (P < .05). RESULTS: The mean number of days defined in the prearthroplasty time period was 69.1 days (standard deviation [SD] 42.8; range 8-191). The mean time spent in each patient’s chart in the prearthroplasty period was 76.8 (SD 47.8) minutes. Surgeon’s work in the medical record accounted for 7.9 (SD 7.9) minutes, registered nurses 46.7 minutes (SD 39.1), physician extenders 10.8 minutes (SD 16.9), and licensed practical nurses and patient care technicians 9.8 minutes (SD 13.0). A significant difference was observed when groups were dichotomized based on age

The start in swimming is a crucial phase of a race, where improvements in performance can be made. Twenty-four elite swimmers race pace starts were recorded from five above and below water 50 Hz video cameras. Body position at toe off was calculated from the recordings and consisted of the two-dimensional mass centre position at toe off, and the arm, trunk, front leg and rear leg angles.Horizontal, vertical and resultant velocity of the mass centre at toe off, time to 5 m, 10 m and 15 m were also determined. Whilst time to 5 m (starting performance) differed by 0.17 s between genders, body position at toe off showed no significant differences. The difference in start performance was mainly due to a difference in horizontal velocity at toe off. The relationship between arm angle and start performance warrants further investigation as there was a range of techniques adopted but no clear link to performance. The trunk angle at toe off was correlated to starting performance for both males and females. This study demonstrates that the body position at toe off is no different between genders but is a critical determinant of starting performance for both males and females.

Isolated patellar resurfacing served as an early treatment for patellofemoral arthritis but was abandoned because of erosion of the native femoral trochlear groove over time. We present the case of a large native tibial osteolytic lesion 20 years after isolated patellar resurfacing with a cemented polyethylene component. The patient had severe tricompartmental arthritic changes. The patellar component was very worn, and the resultant particle debris produced a large cavitary lesion in the proximal tibia. Osteolysis is a rare complication in patellofemoral arthroplasty, and, to our knowledge, this is the first reported case of native tibial osteolysis after isolated patellar resurfacing. The patient was treated with initial curettage and bone grafting of the lesion followed by total knee arthroplasty with a tibial cone and stemmed tibial fixation.

Background Extensor mechanism disruption (EMD) combined with periprosthetic joint infection (PJI) after total knee arthroplasty are life-changing complications. The literature suggests many eventually receive above-knee amputation and lose ambulatory function. An alternative is modular knee fusion (KF), but little is known about its outcomes and biomechanical function. We report early term results on a case series of patients. Methods A retrospective review was conducted of patients who underwent 2-stage reconstruction with modular KF for combined EMD and PJI. Patient-reported outcomes at 1 year after arthrodesis and complications of surgery were recorded. Biomechanical analysis was conducted on 6 patients >1 year after surgery to measure gait speed and balance. Results Fifteen patients received a modular KF. At the most recent follow-up visit (average 25.7 months), 12 patients had their modular KFs in place and were ambulatory while 2 had died. Six patients used a walker; 4, a cane; and 2, unassisted. Gait analysis of 6 of these patients showed variation in patterns and speed. Balance was better than historical controls treated with above-knee amputation. Average Knee Injury and Osteoarthritis Outcome Score Junior was 76 ± 11. Conclusion Modular KF for EMD and PJI can result in successful outcomes in terms of preventing additional operations and maintaining ambulation. While speed is variable, physical testing shows this method for limb salvage may allow patients to ambulate with a gait aid although further studies are needed to evaluate midterm and long-term results.

Pediatric fractures are difficult to manage and often result in expensive urgent transfers to a pediatric trauma center. Our study seeks to identify patients transferred with isolated acute orthopedic injuries to a Level 1 center in which no procedure occurred and the patient was discharged home. We sought to examine all patients who are transferred to a Level 1 pediatric trauma center for care of isolated orthopedic injuries, and to determine how often no procedure is performed after transfer. Identification of this group ahead of time could potentially lead to less avoidable transfers. A retrospective chart review of all patients with isolated orthopaedic injuries who were transferred to a Level 1 pediatric trauma center in a rural state within the United States over a 5-year period beginning January, 2011 and ending December, 2015. Demographic factors were collected for each patient as well as diagnosis and treatment at the trauma center. Patients were divided into two groups, those who underwent an operation or fracture reduction after admission and those that had no procedure performed. Patient demographics, fracture types and presentation characteristics were examined to attempt to determine factors related to the potentially avoidable transfers. 1303 patients were identified who were transferred with isolated orthopedic fractures. Of these, 1113 (85.6%) patients underwent a procedure for their injuries, including 821 treated with surgical intervention and 292 treated with closed reduction of their fracture. 190 of 1303 (14.6%) of the patients transferred with isolated injuries had neither surgery nor a reduction performed. Identifying characteristics of the non-operative group were that they contained a substantially higher percentage of females, transfers by ambulance, fractures involving only the tibia, fracture types classified as other, and fractures from motor-vehicle accidents. Approximately 14.6% of patients transferred to a pediatric Level 1 trauma center for isolated orthopedic injury underwent no surgery or fracture reductions and were discharged directly home. In particular, isolated tibia fractures were more frequently treated without reduction or surgery. In the future, telemedicine consultation for these specific injury types may limit unnecessary and costly transfers to a Level 1 pediatric trauma hospital.

Background Polyethylene liner dissociation is an uncommon complication of hip replacement. Dissociation has been associated with particular acetabular component designs. This study reviewed acetabular liner dissociations in a specific modular cup with a Morse taper locking mechanism that has not been previously reported. Methods The senior author performed 655 primary total hip arthroplasties with one particular design of acetabular component using Class A polyethylene liners and metal head articulation. Cases with revision surgery performed for acetabular liner dissociation were reviewed. Results Seven of 655 patients with this cup underwent revision surgery for a dissociated liner. Liner dissociation occurred at a mean of 73 months postoperatively. Patients presented with new-onset hip pain or squeaking, 4 of which developed symptoms acutely. Two patients treated with polyethylene liner exchange into the same cup required a second revision surgery for recurrent dissociation. Conclusion Polyethylene liner dissociation is an infrequent but possible complication associated with modular acetabular components using a Morse taper locking. Providers should be vigilant with long-term follow-up of patients with this acetabular system for patient complaints of catching or squeaking. Patients treated for liner dissociation should not have a new liner placed into the same acetabular shell given the risk for further dissociation.

Objectives To determine the influence of tracking marker locations on wrist kinematics during free movements and the golf swing, with the intention of recommending a solution that generates meaningful three-dimensional wrist kinematics. Design Repeated measures. Methods Six participants performed free movements of flexion/extension, radial/ulnar deviation and forearm supination/pronation, with a further sixteen participants performing golf drives. A passive motion capture system tracked four different marker sets located on participants’ hand and forearm segments. Variables of peak angle and range of motion were used to compare marker sets during free movements and angles at the top of the backswing and impact were compared during the golf swing. Results Wrist marker set had a large (η2 ≥ 0.557) and often significant (p ≤ 0.051) effect on the variables measured during free movements, and a mixed (η2 ≥ 0.108, p ≤ 0.198) effect on wrist angles during the golf swing. Wrist axial rotation range of motion during free forearm supination/pronation revealed the greatest difference between marker sets (∼42°). The large values generated by two of the marker sets for this rotation appeared to influence the values of flexion/extension and radial/ulnar deviation during the golf swing. Conclusions The location of markers used to measure wrist kinematics can have a large effect on the angles generated. A solution of two markers located at the distal end of the forearm and one at the proximal, appears to minimise values of wrist axial rotation during free forearm supination/pronation and, consequently, produce more meaningful three-dimensional wrist kinematics.

Patients with malignancy are often profoundly immunocompromised due to chemotherapy, placing them at potential increased risk for periprosthetic joint infection (PJI). However, there is little information regarding PJI management in these patients. We describe 4 patients with a history of primary total knee arthroplasty followed by diagnosis of multiple myeloma or Waldenstrom macroglobulinemia who received chemotherapy within 4 months prior to PJI. The Musculoskeletal Infection Society major and minor criteria and either debridement, antibiotics, and implant retention or a 2-stage approach appear to be effective for acute or chronic PJI, respectively. We recommend an anticoagulant be administered concomitantly with antineoplastics that significantly increase deep vein thrombosis risk, and we recommend long-term oral suppressive antibiotics postoperatively, especially if chemotherapy will be resumed. Additional studies are needed to investigate risks and benefits of PJI prophylaxis during chemotherapy and long-term suppressive antibiotics after PJI treatment.