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OBJECTIVE: To describe pulmonary function, muscle strength and functional performance in the different qualities of sleep and the impact of this on the number of physiotherapeutic assistances. METHODS: This is an observational study. In the pre and post operative period, sleep behavior was evaluated using the Pittsburgh questionnaire. Patients were divided into three groups: Good Sleep Quality (GSQ), Poor Sleep Quality (PSQ) and Sleep Disordered (SDB). At this time, other tests were also performed, such as: 6-Minute Walk Test (6MWT), Sit and Stand Test (SST), gait speed test and Timed Up to Go (TUG), Medical Research Council (MRC), maximal inspiratory pressure and maximal expiratory, vital capacity and peak expiratory flow. The functional performance and lung function of each group were compared. RESULTS: A total of 105 people, undergoing cardiac surgery and admitted to hospital were evaluated, 33 with GSQ, 41 with PSQ and 31 with SD. Patients who were in the SDB group had a lower functional performance than the other groups. 6MWT (meters) in the GSQ was 499 ±â€¯87, versus 487 ±â€¯91 in the PSQ and 430 ±â€¯78 in the SD (p = 0.02). In the SST (seconds) it was 10.4 ±â€¯1.1 in the GQS, 11.1 ±â€¯2.3 in the PSQ and 15.4 ±â€¯2.1 in the SD (p = 0.04). Lung function and muscle strength did not differ between groups. Regarding the refusal to perform physical therapy, the SD group was more incident, the main reason being drowsiness. CONCLUSION: Based on the results, we found that sleep quality interferes with functional performance and physical therapy assistance during the hospital stay in patients undergoing cardiac surgery.

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Surgical site infection (SSI) is a devastating complication in patients with neuromuscular scoliosis (NMS) undergoing posterior spinal instrumented fusion (PSIF) for progressive scoliosis. Incisional negative pressure wound therapy (INPWT) has been used in other surgical fields to reduce SSI. Our purpose was to examine the prophylactic use of INPWT after NMS surgery to decrease SSI. At a single institution, 71 consecutive patients with NMS underwent PSIF from 2015 to 2019. Starting in 2017, all patients with NMS received INPWT postoperatively until discharge. Rates of deep SSI were compared between the two cohorts of patients. Additionally, patient demographic and operative factors such as American Society of Anesthesiologists score, number of levels instrumented, need for an anterior spinal release, need for spinal fusion to pelvis, blood loss, operative time, fluoroscopy time, length of stay, and transfusion requirement were analyzed for potential influence on deep SSI. There was no significant difference in deep SSI rates between patients who received INPWT (2 of 41) and those treated with a standard postoperative dressing (2 of 30; P=1.0). Although INPWT theoretically can stabilize the wound environment and prevent deep SSI, our findings do not support this. More research is needed to evaluate the efficacy of INPWT after PSIF for NMS. [Orthopedics. 2023;46(6):373-378.].

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Purpose: To estimate the risk of hospital-acquired COVID-19 transmission in a population of orthopaedic trauma patients during the first wave of the pandemic. Patients and Methods: This is a retrospective cohort study of 109 patients who underwent an emergent orthopedic procedure by a single orthopedic traumatologist between March 1, 2020 and May 15, 2020 during the first peak of the pandemic. After applying inclusion and exclusion criteria, a total of 82 patients (67 inpatients and 15 ambulatory) were identified for final analysis. The primary outcome measured was postoperative Coronavirus (COVID-19) status. Secondary outcome measures included length of stay and discharge disposition. Results: The mean age and length of stay in the hospital group was 59.5 years (± 21.7) and 4.3 days (± 4.6), respectively, versus 47.9 years (± 9.8) in the ambulatory group. 7.3% (6/82) of the inpatients subsequently tested or screened positive for COVID-19 at 2 weeks post-operatively, compared to 0/15 ambulatory patients (P=0.58). Of the 6 inpatients who tested positive, 4 (66.7%) were discharged to a rehabilitation center. Diabetes (P=0.05), hypertension (P=0.02), and congestive heart failure (P=0.005) were associated with transmission. Conclusion: In this analysis, there was a nosocomial transmission rate of 7% compared to zero in the ambulatory surgery center, however this was not found to be statistically significant. This data supports the use of precautions such as frequent screening, hand washing, and masks to reduce transmission when COVID-19 rates are high. There is a lower risk of nosocomial COVID-19 transmission for patients treated as an outpatient and elective surgical procedures may be safer in this setting.

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BACKGROUND: In 2016, the Centers for Disease Control and Prevention (CDC) changed the time frame for their definition of deep surgical site infection (SSI) from within 1 year to within 90 days of surgery. We hypothesized that a substantial number of infections in patients who have undergone fracture fixation present beyond 90 days and that there are patient or injury factors that can predict who is more likely to present with SSI after 90 days. METHODS: A retrospective review yielded 452 deep SSI after fracture fixation. These patients were divided into two groups-those infected within 90 days of surgery and those infected beyond 90 days . Data were collected on risk factors for infection. Univariate and multiple logistic regression analyses were performed to compare the two groups. A randomly selected control group was used to build infection prediction models for both outcomes. The two outcomes were then modelled against each other to determine whether differences in predictors for early versus late infection exist. RESULTS: Of the 452 infections, 144 occurred beyond 90 days (32% [95% CI, 28%-36%]). No statistically significant patient factors were found in multivariable analysis between the early and late infection groups. The need for flap coverage was the only injury characteristic that differed significantly between groups, with patients in the late infection group more likely to have needed a flap. When modelled against the control group and directly comparing the two models, predictors for early infection include male sex and fractures of the pelvis, acetabulum, or hip, whereas predictors of late infection include hepatitis C and/or human immunodeficiency virus (HIV) and admission to the intensive care unit (ICU). CONCLUSION: Use of the recent CDC definition will underestimate the rate of actual postoperative infections when applied to orthopaedic trauma patients. Hepatitis C and/or HIV and ICU admission are predictors of late infection, whereas male sex and pelvis, acetabulum, or hip fractures are predictors of early infection. Patients who receive flap coverage may be more likely to present with late infection.

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BACKGROUND: At peak COVID-19 lockdown, patients with symptomatic atrial fibrillation (AF) were faced with an equipoise between a palliative rate-control versus cautious rhythm-control strategy, including hospitalization for initiation of antiarrhythmic drug/s (AADs) and cardiac procedures which was impossible due to hospitalization restrictions. OBJECTIVES: We aimed to evaluate the efficacy and safety of outpatient initiation of dofetilide in patients with AF using cardiac implantable electronic devices (CIEDs) for rhythm and QTc interval monitoring. METHODS: Adult patients with symptomatic AF with prior failure or intolerance to other AADs were enrolled if they were willing to in-office insertion of implantable loop recorders or already implanted with pacemakers or defibrillators capable of remote monitoring. Exclusion criteria were known medical contraindications of dofetilide and unable to provide consent. After making a shared management decision, dofetilide was initiated in a physician office, and rhythm and QTc intervals were monitored by ECGs and CIEDs. Patients were followed to assess the efficacy and safety of the treatment. RESULTS: The study cohort comprised of 30 patients, age 76 ± 7 years (mean ± standard deviation), 10 female (33%), CHA2DS2-VASc score 3.25 ± 1.3, ejection fraction 63.45% ± 8.52, and QTc interval 431.68 ± 45.09 ms. From 22 (73%) patients in AF at presentation, SR was restored in 14 (64%) patients after 4 doses of dofetilide. At 46 ± 59 days of follow-up, maintenance of SR in total 22 (73%) patients without cardiac adverse effects was accomplished. CONCLUSION: Effective and safe outpatient initiation of dofetilide during the extenuating circumstance of COVID-19 lockdown was possible in patients with AF who had CIEDs.

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In recent years, total hip arthroplasty via the direct anterior approach has been gaining popularity. It offers potential early advantages for less pain and quicker return of hip function; however, compared to other surgical approaches, it is associated with a more difficult femoral reconstruction. Inadequate femoral exposure during the direct anterior approach can result in suboptimal press fit, implant malalignment, and intraoperative fracture. This case report presents a unique complication of femoral broach failure and describes a simple technical solution that is feasible, cost-effective, and safe.

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BACKGROUND: Antiarrhythmic drugs are often used in the management of patients with atrial fibrillation (AF). Sotalol is conventionally initiated in the inpatient setting for monitoring efficacy and adverse effects, including QTc interval prolongation and torsades de pointes (TdP) proarrhythmia. OBJECTIVE: We aimed to evaluate the efficacy and safety of outpatient initiation of sotalol for the treatment of AF in a select group of patients with cardiac implantable electronic devices (CIEDs): permanent pacemakers (PPMs), implantable cardioverter defibrillators (ICDs), and implantable loop recorders (ILRs) capable of continuous rhythm monitoring remotely. METHODS: We conducted our clinical study in a real-world practice setting with longitudinal follow-up of the study cohort. We included adult patients with symptomatic paroxysmal and persistent AF eligible for sotalol for rhythm control strategy and who had CIEDs in our study. Patients with a known contraindication to sotalol were excluded. After making a shared management decision with patients, sotalol was initiated as an outpatient, with regular clinical encounters with patients to assess the efficacy and safety of treatment, and monitoring cardiac rhythm and QTc intervals with CIEDs utilizing their remote monitoring platforms. RESULTS: The study cohort comprised 105 patients; 38 (36%) females, mean age ± standard deviation (SD) 73.9 ± 10.36 years, and with a CHA2DS2-VASc score of 3.26 ± 1.37 and left ventricular ejection fraction of 60.16 ± 9.10%. Twenty-six (24.8%) patients were implanted with PPMs, 10 (9.5%) with dual-chamber ICDs, and 69 (65.7%) with ILRs. Over a follow-up period of 23 ± 15 months, sotalol was continued at a steady median dose of 80 mg twice daily, 105 ± 42 mg (mean ± SD) in 77 (73%) patients who maintained sinus rhythm, and discontinued in 28 (27%) patients because of inefficacy or development of adverse effects. No adverse effects relating to QTc prolongation and TdP or mortality were observed during the study period. CONCLUSIONS: Effective and safe outpatient initiation and maintenance of sotalol therapy is possible in select patients who have CIEDs for continuous remote monitoring and surveillance capabilities.

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SUMMARY: Distal radius fractures are one of the most common fractures seen in orthopaedics. These fractures may be treated surgically or conservatively depending on patient-related and radiographic factors. Displaced fractures should be reduced in the acute setting to better align the fracture fragments and a splint applied to hold the fracture in this position. Fractures that are acceptably reduced may be treated conservatively with casting and close radiographic follow-up to ensure maintained alignment. In this video, we describe our technique for closed reduction of distal radius fractures and review important factors that guide treatment.

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A retrospective case-control study was conducted at a level I trauma center to assess whether radiographic details of tibial plateau fixation can predict symptomatic implant removal. Nine hundred fifty-one tibial plateau fractures were treated with open reduction and internal fixation from 2007 to 2016. Eighty-two (9%) were treated with implant removal for localized pain over the implant. A control group was selected from the remaining patients using cumulative sampling. Records and radiographs were reviewed for predictors hypothesized to be associated with implant removal. Based on the authors' multivariable model, implant removal was associated with each additional protruding screw (adjusted odds ratio, 1.32; 95% confidence interval, 1.13-1.55; P<.001), bicondylar fractures (adjusted odds ratio, 2.13; 95% confidence interval, 1.11-4.11; P=.02), and lower body mass index (P=.05). Associations that approached significance were observed with decreased age (adjusted odds ratio, 0.82 per 10 years; 95% confidence interval, 0.66-1.01; P=.06) and closed fractures (adjusted odds ratio, 0.34; 95% confidence interval, 0.10-1.19; P=.09). The model discriminated fractures requiring implant removal with moderate accuracy (area under the curve=0.71). Each additional screw that radiographically protrudes beyond the far cortex increases the odds of symptomatic implant removal by 32%. Bicondylar fractures and lower body mass index are also associated with symptomatic implant removal. These findings might help inform patients and guide fixation techniques to reduce the likelihood of symptomatic implant removal. [Orthopedics. 2020;43(3):161-167.].

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PURPOSE: We conducted a meta-analysis to determine diagnostic performance of CT intravenous contrast extravasation (CE) as a sign of angiographic bleeding and need for angioembolization after pelvic fractures. MATERIALS AND METHODS: A systematic literature search combining the concepts of contrast extravasation, pelvic trauma, and CT yielded 206 potentially eligible studies. 23 studies provided accuracy data or sufficient descriptive data to allow 2x2 contingency table construction and provided 3855 patients for meta-analysis. Methodologic quality was assessed using the QUADAS-2 tool. Sensitivity and specificity were synthesized using bivariate mixed-effects logistic regression. Heterogeneity was assessed using the I2-statistic. Sources of heterogeneity explored included generation of scanner (64 row CT versus lower detector row) and use of multiphasic versus single phase scanning protocols. RESULTS: Overall sensitivity and specificity were 80% (95% CI: 66-90%, I2 = 92.65%) and 93% (CI: 90-96, I2 = 89.34%), respectively. Subgroup analysis showed pooled sensitivity and specificity of 94% and 89% for 64- row CT compared to 69% and 95% with older generation scanners. CE had pooled sensitivity and specificity of 95% and 92% with the use of multiphasic protocols, compared to 74% and 94% with single-phase protocols. CONCLUSION: The pooled sensitivity and specificity of 64-row CT was 94 and 89%. 64 row CT improves sensitivity of CE, which was 69% using lower detector row scanners. High specificity (92%) can be maintained by incorporating multiphasic scan protocols.

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This study sought to determine (1) whether surgeons can accurately predict functional outcomes of operative fixation of pilon fractures based on injury and initial postoperative radiographs, (2) whether the surgeon's level of experience is associated with the ability to successfully predict outcome, and (3) the association between patients' demographic and clinical characteristics and surgeons' prediction scores. A blinded, randomized provider survey was conducted at a level I trauma center. Seven fellowship-trained orthopedic traumatologists and 4 orthopedic trauma fellows who were blinded to outcome reviewed data regarding 95 pilon fractures in random order. Injury ankle radiographs, initial postoperative fixation radiographs, and brief patient histories were assessed. Midterm follow-up functional outcome scores obtained a mean 4.9 years after surgery were available for all patients. Main outcome measures were Pearson correlation coefficient-assessed functional outcomes and surgeon-predicted outcomes. A mixed-effect model determined the association between patients' characteristics and surgeons' prediction scores. Minimal positive correlation was observed between functional outcomes and prediction scores. No difference was noted between the attending and fellow groups in prediction ability. When surgeons' prediction confidence level was greater than 1 SD above the mean confidence level, correlation between functional outcome and prediction improved, although poor correlation was still observed. AO/OTA type 43C fractures, high-energy mechanisms, and older patient age were characteristics associated with lower prediction scores. Surgeons had poor ability to predict functional outcomes of patients with pilon fractures based on injury and initial postoperative radiographs, and level of experience was not associated with ability to predict outcome. [Orthopedics. 2020; 43(1): e43-e46.].

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OBJECTIVES: To determine factors predictive of postoperative surgical site infection (SSI) after fracture fixation and create a prediction score for risk of infection at time of initial treatment. DESIGN: Retrospective cohort study. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Study group, 311 patients with deep SSI; control group, 608 patients. INTERVENTION: We evaluated 27 factors theorized to be associated with postoperative infection. Bivariate and multiple logistic regression analyses were used to build a prediction model. A composite score reflecting risk of SSI was then created. MAIN OUTCOME MEASURES: Risk of postoperative infection. RESULTS: The final model consisted of 8 independent predictors: (1) male sex, (2) obesity (body mass index ≥ 30) (3) diabetes, (4) alcohol abuse, (5) fracture region, (6) Gustilo-Anderson type III open fracture, (7) methicillin-resistant Staphylococcus aureus nasal swab testing (not tested or positive result), and (8) American Society of Anesthesiologists classification. Risk strata were well correlated with observed proportion of SSI and resulted in a percent risk of infection of 1% for ≤3 points, 6% for 4-5 points, 11% for 6 to 8-9 points, and 41% for ≥10 points. CONCLUSION: The proposed postoperative infection prediction model might be able to determine which patients have fractures at higher risk of infection and provides an estimate of the percent risk of infection before fixation. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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BACKGROUND: Many patients with non-valvular atrial fibrillation (NVAF) with high risk for thromboembolic stroke and bleeding may not wish to continue long-term oral anticoagulants (OACs) to avoid bleeding complications. We aimed to investigate whether AF burden assessment by cardiovascular implantable electronic devices (CIEDs) would allow an individualised disease-guided approach for safe withdrawal of long-term OAC in high-risk patients. METHODS AND RESULTS: We studied 145 patients (age 77.6 ± 10.6 years; 49.7% females) with NVAF, CHA2DS2-VASc score ≥2, HAS-BLED score ≥3, in whom CIEDs were implanted. These patients wished to stay off long-term OAC based on their previous adverse bleeding event/s or due to similar events witnessed in the family or friend circle. These patients were grouped into 'low AF burden' [n = 121 (83%)], or 'high AF burden' [n = 24 (17%)] defined as <24 hours or >24 hours cumulatively in 30 consecutive days respectively, and followed for 51.2 ± 29.8 months. All patients with 'low AF burden' were allowed to discontinue OAC, but OAC was resumed in 1 patient who experienced TIA. Bleeding events developed in 9 out of 24 (37.5%) patients with 'high AF burden' who were maintained on OAC, as compared to 3 out of 121 (2.47%) patients with 'low AF burden' who were off OAC (p <.05). There were 9 (6.2%) deaths unrelated to AF treatment approach. CONCLUSIONS: In NVAF patients, AF burden assessment by CIEDs allows an individualised disease-guided approach to safe withdrawal of long-term OAC in patients with high bleeding risk who do not wish to continue long-term anticoagulation.

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INTRODUCTION: The purpose of this study was to determine the radiographic parameters associated with symptomatic locking screw removal after intramedullary tibial nail insertion. Our hypothesis was that locking screws located closer to joints and those extending longer than the width of the bone result in more symptomatic implant removal. METHODS: We conducted a retrospective cohort study at our Level I trauma center. Seventy-five patients underwent surgical removal of symptomatic locking screws from 2007 to 2014 and were compared with a control group of 122 patients from the same time period who did not undergo symptomatic locking screw removal. Our main outcome measures were radiographic and demographic factors associated with implant removal. RESULTS: Multivariable regression indicated that a proximal locking screw that started anterolateral and was directed posteromedial was the strongest radiographic predictor of symptomatic removal (odds ratio [OR], 2.83; p = 0.03). An Injury Severity Score <11 (OR, 3.10; p < 0.001) and a body mass index <25 kg/m2 (OR, 2.15; p = 0.02) were also associated with locking screw removal. The final prediction model discriminated patients requiring symptomatic locking screw removal with moderate accuracy (area under the receiver operating characteristic curve = 0.73). CONCLUSIONS: The strongest radiographic predictor for symptomatic locking screw removal after tibial nail insertion was the direction of the most proximal locking screw. In contrast to previous research on retrograde femoral nails, tibial locking screws that were closer to the joints were not associated with an increased likelihood of symptomatic screw removal. Clinicians can use these data to help counsel patients regarding the likelihood of symptomatic screws and perhaps to help guide screw placement in cases with multiple options.

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BACKGROUND: Medical recycling and reutilization of cardiovascular implantableelectronic devices (CIEDs) have a significant impact not only in patientsof low-income countries but may also in certain patients in the UnitedStates who do not have sufficient medical insurance coverage. Themain determining factor for future utility and popularity of recycledmedical devices is thorough understanding about this topic amongstpublic and healthcare professional. To the best of our knowledge,there has been no study conducted so far at a community level to determinethe understanding in public and healthcare personnel about recyclingof medical devices including CIEDs. We sought to determine existingknowledge and attitude about recycling of CIEDs amongst representativesample population in a community. METHODS: A questionnaire was sent for online completion to multiple peoplein the community, healthcare and funeral home in Lehigh Valley, Pennsylvania,USA. The questionnaire was designed in order to assess three maincategories; knowledge, attitude and practice. We called this a KAPstudy which is an acronym for knowledge, attitude and practice survey. RESULTS: We got 117 responses to our questionnaire from community members(55.45%), 89 responses (42.18%) from the healthcare personnel andfive responses (2.37%) from funeral homes. About 30.77% communityparticipants had heard about medical devices recycling compared to57.30% participants from healthcare sector. A total of 88.64% of medicalprofessionals were aware that there are people in the world who diebecause they cannot afford CIEDs while 73.50% of community participantswere also found to be aware of this fact. Higher percentages of healthcareprofessionals were found to be willing to personally consider a decisionabout medical device donation compared to community participants. CONCLUSIONS: CIED reutilization can improve quality of life among many patientswith low or medium socioeconomic status. People should be made moreaware about the benefits of CIED reutilization. Concerns about device-relatedinfections, complications and law suits should be addressed to helpimprove their utility.

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BACKGROUND Hydralazine is an effective antihypertensive agent but may rarely have devastating hepatotoxic effects that are extremely variable, thus making the diagnosis difficult. CASE REPORT We report the case of a 74-year-old male patient who had transaminitis after being started on hydralazine by his cardiologist for poorly controlled hypertension. He had extreme dizziness, nausea, and weakness, which all resolved after discontinuation of hydralazine, and liver function test results also dramatically improved. CONCLUSIONS It is imperative that clinicians be aware of the possible hepatotoxicity of hydralazine and its clinical features so that the medication can be promptly discontinued to help promote liver recovery. This case report will add to the current literature about such infrequent cases of hydralazine-induced hepatotoxicity.

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BACKGROUND: We conducted a retrospective analysis to revisit the efficacy of four different commonly used antiarrhythmic drugs (AADs) in a single community hospital setting in the U.S. We used cardiac implantable electronic devices (CIEDs) to continuously monitor the patients for maintenance of sinus rhythm. The CIEDs in our study included insertable cardiac monitor (ICM), permanent pacemaker (PPM) and cardiac resynchronization therapy-defibrillator (CRT-D). The aim was to compare efficacy of commonly used AADs for maintenance of sinus rhythm in atrial fibrillation (AF) patients. METHODS: We conducted our retrospective study in a real world practice setting. We analyzed electronic medical records of 145 consecutive patients with paroxysmal and persistent AF who were treated with AADs for maintenance of sinus rhythm between the period of April 2014 and February 2018. RESULTS: Total 34 out of 145 patients (23.45%) had AF recurrence. The mean duration of first AF recurrence in total patient cohort was 18.01 ± 12 months. There was no major difference in efficacy in terms of prevention of first episode of AF recurrence among commonly used class III and class IC AADs. CONCLUSIONS: Higher doses clearly seem to be more effective in preventing the recurrence of AF in class III AADs; sotalol and amiodarone. Use of CIEDs helps to continuously monitor patients for recurrence of AF and detects proarrhythmic effects of AADs.

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There has been an increase in number of cardiac implantable electronic devices (CIEDs) implantation and with this we have witnessed increased rates of CIED infection mainly in elderly population. It is important to assess conditions that may not reliably improve with cardiac pacing or those who lack adequate beneficial effect from permanent pacing before contemplating implantation or reimplantation of these devices. Sometimes, the initial cardiac pathology may revert obviating the need for reimplantation as in the two cases that we have discussed below. This reduces the chance of further infection of CIED, and decreases mortality and morbidity due to recurrent CIED infection and decreases cost of care.