INTRODUCTION: Femoral shaft fractures are significant injuries with a predominately traumatic etiology. Intramedullary nailing is the preferred surgical intervention, and reduction of the fracture can be accomplished through closed or open methods. Closed reduction is often considered the gold standard as it is theorized that an intact fracture hematoma has osteogenic properties that will result in superior healing with fewer complications. Open reduction procedures persist in cases of polytraumatic injury, when the fracture proves difficult to reduce by closed methods, or in geographical areas with limited resources. Studies comparing outcomes between the treatments have conflicting results. The purpose of this systematic review and meta-analysis was to compare the outcomes and complications of intramedullary nailing of femoral shaft fractures between open and closed reduction. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, PubMed (MEDLINE), Embase, Scopus, and CENTRAL were searched to identify comparative studies up to May 2022. Additional studies were identified through hand and citation searching. Exclusion criteria included pediatric patients younger than 17 years of age, studies not published in English, and studies that reported fractures of the proximal or distal femur. The primary outcome was the rate of union. Secondary outcomes included time to union, operative time, and complication rate. RESULTS: Closed reduction had a higher pooled union rate (93.93%, 92.02%), an increased odds ratio for union (OR =1.624 [95% CI: 1.004, 2.624]; p =.048), and a faster time to union (SMD = -0.292 [95% CI: -0.549, -.0.035]; p =.026). There were no differences in operative time (SMD = .128 [95% CI: -0.700, .956] p = .762) or overall complication rate (OR = 1.314 [95% CI: .966, 1.787] p = .082). DISCUSSION AND CONCLUSION: Closed reduction has the advantage of higher union rates, quicker time to union, and lower overall infection compared to open reduction for intramedullary nailing of femoral shaft fractures. Open reduction remains a reasonable alternative with acceptable union rates when closed reduction is not feasible.

Background Opioid overdose has been on the constant rise since the beginning of the opioid epidemic. Orthopedic surgery has the 3rd highest average number of opioid prescriptions per prescriber. Efforts have been made nationally to decrease opioid prescribing and opioid use and abuse. Studies have shown patients with mental health disorders are more likely to be prescribed medications, such as opioids, for chronic pain management. This study aims to investigate the trends in prescription rates of analgesic medications for primary total shoulder arthroplasty (TSA) patients with a history of mental illness, chronic pain, or substance use. Methods A retrospective trends analysis was performed using a national database. Patients who underwent primary TSA were identified using the International Classification of Disease. Patients with diagnoses of mental illness, pain syndromes, and substance use were compared to a control group without diagnoses. Patients with a history of an opioid prescription claim within 6 months before TSA were excluded. Medications prescribed—opioids, gabapentinoids (GBPs), and nonsteroidal anti-inflammatory (NSAIDs)—were identified using Uniform Systems of Classification and codes specific to the database. Annual medication claims rates within 30 days, 90 days, and 1-year after TSA were analyzed with linear regression and compound annual growth. Results A total of 82,692 patients with a history of mental illness, chronic pain, or substance use underwent primary TSA. Among this cohort of patients, opioid prescription claims had significantly increasing trends by 30-days after surgery, however, trends were significantly decreasing by 90-days and 1-year after surgery. Prescription claims for GBPs were significantly increasing by all timepoints after TSA surgery among this cohort. For NSAIDs, prescription claims significantly increased by 30 and 90-days post-surgically while decreasing by the 1-year mark. Conclusion Patients with a diagnostic history of mental health, chronic pain, or substance use have significantly fewer opioid medication prescription claims after total shoulder arthroplasty surgery than patients who do not have those diagnoses. No difference in average prescription claims was observed between groups with GBPs or NSAIDs in the 30-day or 90-day postoperative periods.

Background: YouTube is a video platform for many topics, including plastic surgery. Previous studies have shown poor educational value in YouTube videos of plastic surgery procedures. The purpose of this study was to evaluate the quality and accuracy of YouTube videos concerning gynecomastia surgery. Methods: The phrases “gynecomastia surgery” (GS) and “man boobs surgery” (MB) were queried on YouTube. The first 50 videos for each search term were examined. The videos were rated using our novel Gynecomastia Surgery Specific Score (GSSS) to measure gynecomastia-specific information, the Patient Education Materials Assessment Tool (PEMAT) to measure understandability and actionability, and the Global Quality Scale (GQS) to measure general quality. Results: The most common upload source was a board-certified plastic surgeon (35%) and content category was surgery techniques and consultations (51%). Average scores for GQS (x̄ = 2.25), GSSS (x̄ = 3.50), and PEMAT Actionability (x̄ = 44.8%) were low, whereas PEMAT Understandability (x̄ = 77.4%) was moderate to high. There was no difference in all scoring modalities between the GS and MB groups. Internationally uploaded MB videos tended to originate from Asian countries whereas GS videos tended to originate from non-US Western countries. Patient uploaders had higher PEMAT Actionability scores than plastic surgeon uploaders. Conclusion: The quality and amount of gynecomastia-specific information in gynecomastia surgery videos on YouTube is low and contains few practical, take-home points for patients. However, understandability is adequate. Plastic surgeons should caution their patients that YouTube as a source of information for gynecomastia surgery may be unreliable.

Background: Femoral nerve palsy can cause gait deficits and knee instability. For its treatment, nerve transfers are preferred. However, this approach is only applicable for a limited window of time. For patients outside of this window or when nerve transfers are not technically feasible, musculotendinous transfers represent a viable alternative. Case Presentation: A 39 years-old female suffered a complete transection of the femoral nerve within the pelvis during proximal thigh schwannoma resection. Three years postoperatively she presented with antalgic gait, atrophy of the quadriceps, 0/5 strength in knee extension, and loss of thigh sensation. EMG revealed complete femoral nerve palsy with no recruitment of the quadriceps, sartorius, and iliopsoas muscles. The patient elected to undergo an adductor magnus, gracilis, and TFL musculotendinous transfer to the quadriceps tendon. This approach aimed to balance forces by harvesting a hip flexor and hip adductor while preserving hip adductor function by leaving the adductor longus muscle intact. Intraoperatively, the gracilis tendon was weaved into the vastus medialis and medial quadriceps tendon. The adductor magnus was weaved into the rectus femoris and vastus intermedius tendons. The IT band was weaved into the vastus lateralis and rectus femoris. By 11 months post-op she had 4/5 in right knee extension and hip flexion strength. Gait analysis revealed active recruitment of the gracilis, TFL, and adductors with improved walking speed and gait symmetry without requiring assistive devices. Discussion: Given the extent, proximal location, and chronicity of her femoral nerve injury, nerve transfers were not feasible for this patient. Therefore, we opted for a musculotendinous transfer. We used multiple leg muscles to attain sufficient knee extension strength. To simplify surgery and recovery we selected easily mobilized muscles with long tendons innervated by her healthy obturator nerve. This technique also had a shorter recovery time as reinnervation is not needed. Nonetheless, to relearn basic motor patterns with a new set of muscles and innervations, the patient underwent rehabilitation involving six weeks of immobilization followed by passive rage-of-motion movements and active strength-building exercises. Our subject’s EMG findings, lack of falls, and functional gait improvements further demonstrate these rehabilitation methods’ efficacy.

Abstract Title: SLCO1B1*5 allele is associated with atorvastatin discontinuation and adverse muscle symptoms in the context of routine care Background SLCO1B1 genotype is known to influence patient adherence to statin therapy, in part by increasing the risk for statin-associated musculoskeletal symptoms (SAMS). For simvastatin specifically, the SLCO1B1*5 allele has previously been associated with SAMS. For atorvastatin, prior studies assessing the impact of SLCO1B1*5 on SAMS have yielded inconclusive findings, due to insufficient power. Methods This study quantifies the impact of SLCO1B1*5 on atorvastatin discontinuation and SAMS in a large observational cohort using electronic medical record (EMR) data from a single health care system. Results In the study cohort (n = 1,627 patients exposed to atorvastatin during the course of routine clinical care), 56% (n = 912 of 1,627 patients) discontinued atorvastatin, and 18% (n = 303 of 1,627 patients) developed SAMS. A univariate analysis revealed that SLCO1B1*5 increased the likelihood that patients would stop atorvastatin during routine care (Odds Ratio 1.2, 95% confidence interval [C.I.]: 1.1 - 1.5, p = 0.04). Further analyses using a multivariate Cox proportional hazards model demonstrated that this same variant was associated with time to atorvastatin discontinuation (Hazard Ratio 1.2, C.I. 1.1 - 1.4, p = 0.004). Additional time-to-event analyses also revealed that SCLO1B1*5 was associated with SAMS (Hazard Ratio 1.4, C.I. 1.1 - 1.7, p = 0.02). Conclusion Atorvastatin discontinuation was associated with SAMS (Odds Ratio 1.67, p = 0.0001) in this cohort. It is plausible that SLCO1B1-informed statin therapy with the aim of reducing muscle side effects may lead to improved adherence for this important class of drugs.

Background: Patellar Tendinopathy (Jumper’s Knee) affects up to 17% of the general population and may become recalcitrant in up to 20% of cases. While these cases often require surgery, it is unclear whether an open or arthroscopic procedure should be performed. Methods: A systematic search of articles published 2000-present studying outcomes after surgical intervention for patellar tendinopathy was performed across PubMed, Embase, CINAHL, Scopus, and Cochrane databases and screened using PRISMA guidelines. Outcomes assessed included Patient Reported Outcome Measures (PROM), ie Victorian Institute of Sports Assessment (VISA-P), Visual Analog Scale (VAS), modified Blazina, Lysholm, Tegner, IKDC, and SANE scores, and subjective Success and Return to Sport (RTS) data at follow-up. Descriptive statistics with weighted averages were used to assess differences between groups but no meta-analysis was performed due to heterogeneity of intervention groups. Results: 21 studies were included for analysis that analyzed 13 arthroscopic, 8 open, and 2 combined treatment groups with follow-up ranging from 6-96 months. 2 retrospective studies directly compared open vs arthroscopic and reported earlier RTS time in arthroscopic patients (mean 5.5 vs 8.0mo) but no differences in VISA-P, overall success, or RTS rate. Open surgical patients required repeat surgery in 4 instances. Summary analysis of all data showed arthroscopic patients had earlier RTS (3.8 vs 8.7mo) and slightly higher RTS rate (88.5% vs 74.9%), but similarly high rates of overall success (89.1% vs 83.1%). Arthroscopic groups generally had higher average VISA-P and Blazina scores compared to Open groups. Combined open/arthroscopic procedures exhibited a mean success and RTS rate of 86.6% and 91.3%. Complications were reported in 3 open groups (surgical site complication, repeat surgery required, algodystrophy), 2 arthroscopic groups (failed tendon release, new-onset PFPS), and 1 combined group (repeat surgery required). Conclusions: In patients with refractory patellar tendinopathy and varying baseline activity levels, both open and arthroscopic surgical approaches, as well as combined procedures, lead to high rates of success and return to sport. Arthroscopic approaches may lead to quicker return to sport and greater improvements in patient-reported outcome measures than open procedures. Clinical Relevance: Arthroscopic intervention may yield similar or better clinical outcomes compared to open techniques with quicker return to sport for patellar tendinopathy refractory to conservative management.

Aggressive natural killer cell leukemia (ANKL) is a rare neoplastic malignancy, especially in pediatric populations with very few cases reported in the literature. It commonly presents with a rapidly declining clinical course and has a median survival of two months. We report the case of a 15-year-old female who presented with fever, hepatosplenomegaly, hemophagocytosis, and disseminated intravascular coagulation (DIC). The patient was ultimately diagnosed with ANKL but died after developing multiorgan failure and DIC prior to the initiation of any treatment. In this case report, we review and discuss the literature concerning the diagnosis and treatment of ANKL in pediatric patients.

Background Diagnostic fluorescein angiography (FA) is a routine in-office imaging modality that aids in the diagnosis, monitoring, and treatment of various retina diseases. This imaging procedure requires a standard dose of intravenous injection of 5 mL fluorescein sodium (FS) 10% 500mg. Up to 20% of the population may experience mild to moderate adverse reactions such as nausea and vomiting and less than 1% have experienced a severe reaction of anaphylaxis after receiving FS. Past studies rejected the use of half dose 2.5 mL FS due to poor image quality. With recent updates in scanning laser ophthalmoscopy, a full dose of 5 mL may not be necessary, and half the standard dose may be adequate using newer wide-field angiography. We hypothesize that the incidence of adverse reactions will significantly decrease with half dose FS compared to the standard 5 mL dose. Methods A prospective study measuring the incidence of five adverse reactions (ARs) including nausea, vomiting, dizziness, lightheaded, and hot/ warm sensation during and following the procedure with 5 mL (standard) versus 2.5 mL (half dose) FS was compared. Results An independent t-test revealed the incidence of having at least one AR was significantly different between groups (p<0.05). 15.8% of individuals who received 5 mL FS experienced at least one AR, compared to 9.1% of individuals who received 2.5 mL FS (n = 202, 253). Of those who received 5 mL FS, 11.9% experienced nausea, 4.5% experienced vomiting, 5.4% experienced lightheadedness, 5.4% experienced dizziness, and 3.5% experienced vomiting compared to 7.5%, 1.6%, 0.8%, 0.4%, and 0% of participants who received 2.5 mL FS, respectively. Conclusion This was a significant decrease in ARs for patients who received half dose FS. This has potential to aid patients who previously could not tolerate the full dose due to ARs.

Background: At present, damage to nervous tissue is difficult to treat, often irreversible, and furthermore nerve growth to new sites is very limited. I hypothesize that teeth have a special capability to induce nerves and that we can isolate tissues and factors that could be used in a clinical setting to completely regenerate nerves. In human clinical studies where developing third molar teeth have been transplanted to donor sites, the teeth have continued to grow but more astoundingly have gained the ability for nociception in response to cold stimuli. This finding implies that developing teeth transplanted to a bony defect induce de-novo nerve growth at the recipient site. In this working study I utilize the rat model to demonstrate de-novo nerve growth by transplanting whole teeth to iatrogenic bony-defects created in autologous tibia and performing histological and biochemical analysis. Demonstrating innervation in transplanted teeth of post-natal rats would indicate that dental tissues are indeed capable of nerve growth and would greatly enhance our understanding of nerve induction. Methods: Post-natal rats (Sprague-Dawley) aged 28-30 days were anesthetized and intact tooth germs with fully developed crowns undergoing root development were isolated. A bony defect was then created in the ipsilateral anterior tibia and the extracted tooth was transplanted to the defect. The wound was closed and hemostasis established. Hematoxylin and Eosin staining, and fluorescent immunohistochemistry were performed for nerve specific markers including anti-acetylated tubulin III antibodies. Results: Histology reveals a tooth well integrated into the tibia and a significant reduction in inflammation and bony remodeling, with dental specific enamel and dentin present in the leg. Moreover, the transplanted tooth is vascularized and early immunohistochemistry indicates evidence of innervation of transplanted teeth in line with the hypothesis that teeth have nerve inductive capacity postnatally. Conclusion: Teeth transplanted autologously to tibia can integrate into the leg, survive as independent organs with their own blood supply, and early histology indicates innervation of the transplanted tooth. These data are applicable to patients’ needing re-innervation of eye, spine, extremity, teeth and many other organs. The implications are far-reaching and may lead to novel nerve regeneration therapeutics.

Abstract Title: Tissue Anchoring Nanomedicine Alleviates Osteoarthritis Knee Model in Mice Background Osteoarthritis (OA) is the most common joint disorder in the United States. The CDC estimates more than 32.5 million US adults suffer from clinical OA. According to the AAOS evidence-based guidelines, intraarticular anti-inflammatory therapy is the first line treatment for knee OA. Currently available therapies have critical shortcomings, primarily the inability to modify pathophysiological disease progression limiting treatment solely to palliative care. Further, rapid clearance of these drugs from the joint space limits therapeutic potential and results in systemic side effects. Given the established anti-inflammatory potential and readily modifiable structure of nanoparticle fullerene (C60), we attempt to develop a more precise treatment for knee OA. Methods We have previously developed a targeted C60 nanoparticle composed of a C60 cage with a conjugated cFLFLF peptide (cFLFLF-C60) that binds specifically to formyl peptide receptor-1, a receptor abundantly expressed on activated macrophages. Using Raw 264.7 macrophages, Lipopolysaccharide, and the Cy5 fluorophore integrated in the cFLFLF peptide, the nanoparticle’s preferential binding was evaluated, and anti-inflammatory efficacy analyzed by PCR. Ten to 12-week-old Balb/c mice underwent destabilization of middle meniscus (DMM) surgery to induce OA, with seven mice receiving a cFLFLF-C60 injection and six serving as control (injected with saline). IVIS imaging was then used to evaluate the functionalized-C60’s distribution 2 weeks post-injection. After 6 weeks, the mice were sacrificed, and the knee joints scanned and analyzed by microCT as well as sectioned and stained for histological analysis. Results The cFLFLF-C60 demonstrated preferential binding to LPS-stimulated macrophages versus non-inflammed macrophages. IVIS imaging revealed significant retention within the injured knee joint compared to fluorophore-labeled saline. MicroCT analysis revealed that compared to control mice joints, cFLFLF-C60 effectively attenuated OA morphological changes (subchondral sclerosis, osteophyte formation) and restored trabeculae morphological parameters back to those of sham group (trabeculae number, spacing, and connectivity density). Histologic analysis revealed improved OARSI grading and tidemark measurements in the cFLFLF-C60 cohort. Conclusion cFLFLF-C60 preferentially anchors to activated macrophages, leading to significantly increased joint space retention. The pathophysiological changes that define OA were attenuated by intra-articular injection of cFLFLF-C60 as confirmed by microCT and histological analysis.