Michael C. Willey

Mental health disorders are common in young people with musculoskeletal conditions. This study aims to report the prevalence of self-harm ideation in adolescents and young adults with hip conditions, the association with psychological distress, and the impact of treatment on self-harm ideation prevalence. Five hundred consecutive patients presenting to an adolescent and young adult hip clinic completed the Optimal Screening for Prediction of Referral and Outcome Yellow Flag and the Patient Health Questionnaire-9. The primary outcome was self-harm ideation (yes/no). Patients reporting self-harm were matched 1:1 with those who reported none/mild and severe psychological distress without self-harm ideation. Chi-square or Fisher’s exact tests assessed differences between those with and without self-harm ideation. Self-harm ideation was reported by 24/500 (4.8%). Those with severe psychological distress were significantly more likely to report self-harm ideation when compared to those with none/mild distress (OR = 7.9, adjusted P < .001) or moderate distress (OR = 4.9, adjusted P = .002). Hip surgery was performed in 19/24 patients that reported self-harm ideation. After surgery, 73% (11/15) reported resolution of self-harm ideation. Pre-operative self-harm ideation was associated with a decreased improvement in International Hip Outcome Tool-12 after surgical treatment compared to none/mild (mean 22.9 vs 48.0, P = .005), or severe psychological distress (mean 22.93 vs 41.17, P < .05) without a positive response to self-harm ideation. Self-harm ideation is present in about 1 in 20 adolescents and young adults who present for evaluation of hip pain and is associated with psychological distress. After appropriate psychological care and surgical treatment, self-harm ideation resolved in three-of-four patients.

Purpose: Operative management of proximal humerus fractures with glenohumeral dislocation is often delayed until a shoulder specialist is available. This study aims to assess whether time from presentation to operative intervention impacts incidence of neurologic injury in the preoperative waiting period. Methods: Retrospective review was performed for patients undergoing operative management of a proximal humerus fracture dislocation at a level 1 trauma center. Patient charts were reviewed for patient factors, injury characteristics, neurologic status, and postoperative complications. Statistical analysis comparing patients undergoing operative intervention ≤ 5 and > 5 days from injury was performed (α ≤ 0.05). Results: Of 52 proximal humerus fracture dislocations, 14% had a neurologic deficit at presentation, and 1.9% had a change in neurologic status prior to operative intervention. 32 injuries (61.5%) underwent operative intervention ≤ 5 days from presentation and 20 (38.5%) > 5 days. There was no difference in neurologic deficit at time of presentation (18.8% vs. 10.0%, p =.077), incidence of preoperative neurologic exam change (0% vs. 5.0%, p =.38), or residual neurologic deficit at final follow-up (9.4% vs. 5.0%, p = 1.0) for the ≤ 5 or > 5 day cohorts, respectively. Conclusion: Through this exploratory retrospective study, no differences were identified for rates of neurologic injury development in the preoperative waiting period between patients undergoing operative intervention ≤ 5 days or > 5 days from presentation for proximal humerus fractures with glenohumeral dislocation, however, this is limited by only 1 patient experiencing a preoperative neurologic change in the > 5 days group. Given the rarity of neurologic injury in the preoperative waiting period and low power of this study, future larger prospective studies are needed to better define the impact of waiting for operative intervention for these injuries. Level of Evidence: Level IV Case Series.

The natural history of osteoarthritis development in individuals with hip dysplasia diagnosed after skeletal maturity is difficult to predict. While reorienting acetabular osteotomy improves pain and function for those with pre-arthritic hip dysplasia, the impact of dysplastic deformity correction on cartilage health and future cartilage degeneration remains unknown. The rabbit has been used as a preclinical model of hip dysplasia for investigation of joint degeneration and surgical treatment, but there is variability among protocols used to induce and characterize dysplastic deformity. The aim of this narrative review was to summarize techniques for inducing hip dysplasia, the associated morphologic and histopathologic changes, and the ability of surgical correction to mitigate joint degeneration in order to guide future research using the rabbit as a model of hip dysplasia. We identified 21 studies that induced dysplastic deformity in the rabbit hip. The most common method to induce dysplastic deformity was immobilization of the knee in extension in skeletally immature rabbits. Immobilization initiated at a younger age and for longer duration resulted in more severe dysplasia. In the few studies that assessed surgical treatment of the dysplastic hip, cartilage degeneration was reduced with correction of dysplastic deformity. We concluded that immobilizing skeletally immature rabbit knees in extension reliably causes dysplastic deformity of the hip, replicating a shallow and abnormally oriented acetabulum, which can progress to full dislocation more characteristic of hip dysplasia in infants and children, or be present without complete femoral head dislocation more characteristic of human hip dysplasia that presents in young adults. This model thereby offers the opportunity to assess the tissue level effects of hip dysplasia and the effects of surgical correction across the age spectrum. Clinical trials number : Not applicable.

Hip dysplasia is currently diagnosed with two-dimensional radiographic measurements that may not adequately describe the aetiology of pain and dysfunction associated with dysplastic deformity and future osteoarthritis progression. This study aimed to assess how accurately two-dimensional radiographic measurements represent the three-dimensional mechanical joint environment. Spearman ρ correlation was used to determine associations between radiographic measurements of hip dysplasia made on pre-operative and 6-month post-operative standing AP pelvis radiographs, and hip contact stress calculated based on pre- and post-operative pelvis CT scans for a series of 100 patients (125 dysplastic hips) treated with periacetabular osteotomy using discrete element analysis. Only moderate correlations were observed between radiographic measurements and contact mechanics. Pre-operative lateral centre edge angle of Wiberg had the highest, though moderate, correlation with mean cumulative contact stress-time exposure (ρ = −0.5112, P < .0001). Tönnis angle (ρ = 0.4898, P < .0001) and extrusion index (ρ = 0.4579, P < .0001) also had moderate correlations with pre-operative mean cumulative contact stress-time exposure. Only weak correlations were found post-operatively and when comparing change in radiographic measurements to computational contact mechanics metrics before and after surgery. These findings indicate the mechanical environment of the hip joint is more complex than simple radiographic measurements that quantify coverage of the femoral head by the acetabulum. Evaluation of three-dimensional contact mechanics in dysplastic hips should be used in combination with two-dimensional radiographic evaluation for guiding clinical care for patients with hip dysplasia.

This study investigated the relationship between three‐dimensional (3D) acetabular coverage and contact mechanics in dysplastic and ostensibly normal hips. Fifty asymptomatic hips previously imaged with CT scans/angiograms were matched on a 2:1 basis to 25 dysplastic hips with previous CT imaging, based on age, gender, weight, and BMI. CT imaging was used to create 3D patient‐specific hip models from which the 3D coverage metrics of subchondral arc angle (i.e., acetabular weight‐bearing morphology) and hip joint coverage angle (i.e., femoral head coverage), and the congruity metrics of acetabular sphericity index (i.e., sphericity of the acetabulum) and joint congruity index were assessed globally and in five octants spanning the weight‐bearing acetabulum. Discrete element analysis was used to calculate hip contact mechanics, with results assessed globally and subdivided into the same five octants. Increasing superior‐anterior subchondral arc angle was associated with increasing superior‐anterior mean chronic contact stress‐time exposure in dysplastic hips, which was significantly (p < 0.001) different from asymptomatic hips where increasing superior‐anterior subchondral arc angle was associated with decreasing superior‐anterior mean chronic contact stress‐time exposure. Similarly, increasing joint congruity anteriorly was associated with increasing anterior mean chronic contact stress‐time exposure in dysplastic hips, which was significantly (p = 0.003) different from the trend of decreasing anterior mean exposure with increasing anterior in asymptomatic hips. These results indicate fundamental differences in how contact mechanics in asymptomatic and dysplastic hips respond to differences in acetabular coverage and joint congruity, suggesting that asymptomatic hips follow the expected geometry‐based trend, while dysplastic hips do not.

Background: Psychological distress is increasing in adolescents and young adults, but comprehensive screening programs are not commonly incorporated into orthopaedic clinical practice. We implemented a screening program for depression symptoms and psychological distress in adolescents and young adults with hip pain. The aims of this study were to report the prevalence and risk factors and determine the relationship with patient-reported pain and dysfunction. Methods: Patients 10 to 24 years of age presenting for hip pain at an initial clinic visit completed the Patient Health Questionnaire-9 (PHQ-9), the 17-item Optimal Screening for Prediction of Referral and Outcome-Yellow Flag (OSPRO-YF) tool, and the International Hip Outcome Tool-12 (iHOT). Two outcome levels for depression symptoms using the PHQ-9 were compared (mild or less versus moderate or greater), and 3 outcome levels for psychological distress using the OSPRO-YF were compared (none or mild versus moderate versus severe). Age, sex, body mass index, previous surgery, and the hip diagnosis were entered into logistic regression models to predict outcomes for the levels of depression symptoms and psychological distress. iHOT scores were compared between groups using the Wilcoxon rank-sum test and the Kruskal-Wallis test followed by pairwise Wilcoxon rank-sum tests. Results: Among 500 patients who completed screening, 10.6% had moderate or greater depression symptoms and 26.9% had severe psychological distress. Multivariable logistic regression revealed that young adults (age, 20 to 24 years) had higher odds of moderate or greater depression symptoms compared with adolescents (age, 10 to 19 years) (odds ratio, 2.09; p = 0.016). Female patients (risk ratio [RR], 1.86; p = 0.026), patients who had undergone a prior surgery (RR, 2.29; p = 0.025), and overweight patients (RR, 2.10; p = 0.008) had a higher risk of severe psychological distress. Both moderate or greater depression symptoms and increasing levels of psychological distress were significantly associated with lower iHOT scores (all p < 0.001). Conclusions: Psychological distress was common in adolescents and young adults with hip pain and was associated with greater patient-reported hip pain and dysfunction. Young adults had a greater risk of depression symptoms. Severe psychological distress was more common in female patients, overweight patients, and those who had undergone failed prior hip surgery. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: A preoperative chlorhexidine gluconate (CHG) bath is used to reduce the risk of surgical site infection (SSI) in elective surgery, but its efficacy in the trauma setting is unknown. We compared the incidence of SSI between patients who did versus did not receive a CHG bath before operative fixation of extremity and/or pelvic fractures. Methods: We conducted a secondary analysis of the PREP-IT cluster-randomized crossover trials that enrolled patients undergoing operative treatment for open or closed extremity or pelvic fractures. Preoperative CHG bathing (yes or no) was recorded for each patient per study protocol. The association between CHG bathing and SSI within 90 days after definitive fracture surgery was assessed. We performed multivariable regression to adjust for prognostic variables. We also conducted a separate instrumental variable analysis to compare SSI rates between study sites that used CHG bathing for >90% of participants and those that used CHG bathing for <1% of participants. Results: Of the 10,103 participants (mean age, 51 ± 20 years; 47% female; 77% White; 17% Black; 4% Asian; 7% Hispanic) included in the analysis, 2,674 (26%) had a documented preoperative CHG bath and 7,429 (74%) did not. CHG bathing was not associated with a significant reduction in the odds of 90-day SSI in the multivariable (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.86 to 1.32; p = 0.56) or instrumental variable (OR, 0.88; 95% CI, 0.62 to 1.25; p = 0.48) analyses. Conclusions: Among adult patients who underwent extremity or pelvic fracture surgery, preoperative CHG bathing was not associated with a significant reduction in SSI. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To identify risk factors for methicillin-susceptible (MSSA) and methicillin-resistant S. aureus (MRSA) nasal carriage and surgical site infection (SSI) among patients undergoing fracture fixation procedures who were included in a quality improvement protocol involving screening patients for S. aureus nasal carriage and treating carriers with intranasal mupirocin and chlorhexidine bathing.Design: Retrospective cohort study.Setting: Level 1 trauma center.Participants: 1,254 adults who underwent operative fixation of 1,298 extremity or pelvis fractures between 8/1/2014 – 7/31/2017.Methods: We calculated rates of S. aureus nasal carriage and SSI. We used multivariable stepwise logistic regression and selected the final models based on Akaike information criterion.Results: Of the 1,040 screened first procedures, 262 (25.19%) were performed on S. aureus nasal carriers: 211 (20.29%) on MSSA carriers and 51 (4.90%) on MRSA carriers. Long-term care facility residence (odds ratio [OR] 3.38; 95% confidence interval [CI] 1.17–9.76) was associated with MRSA nasal carriage. After adjusting for statistically and clinically significant variables, MRSA carriage was significantly associated with any SSI (OR 4.58; 95% CI 1.63–12.88), S. aureus SSI (OR 10.11; 95% CI 3.25–31.42), and MRSA SSI (OR 27.25; 95% CI 5.33–139.24), whereas MSSA carriage was not. Among S. aureus carriers, any chlorhexidine use was documented for 232 (88.55%), and any intranasal mupirocin was documented for 85 (40.28%) MSSA carriers and 33 (64.71%) MRSA carriers.Conclusions: MRSA carriage was associated with a significant risk of SSI after operative fracture fixation. Many carriers did not undergo decolonization, suggesting that a simplified decolonization protocol is needed.

Introduction: Food insecurity is the condition of limited access to healthy and safe food. Malnutrition resulting from food insecurity is a concern particularly in the surgical population due to the association with impaired healing. This aim of this study was to report the incidence and risk factors for food insecurity in the orthopaedic trauma population. Methods: Orthopaedic trauma centers at three distinct regions of the United States enrolled patients who had undergone extremity or pelvis fracture fixation within the previous 6 months. Participants completed the United States Department of Agriculture Household Food Insecurity Survey, and food insecurity was defined as a score ≥3. In addition, participants recorded patient demographics and injury/treatment/household characteristics and completed information about diet quality. Diet quality was compared between households with and without food insecurity using chi-square or Fisher exact tests. Logistic regression was used to create a multivariable model of factors associated with greater odds of food insecurity. Results: Food insecurity was documented in 11.5% (81/703) of households. Households with food insecurity were less likely to report daily consumption of fruit, vegetables, and protein-rich foods. We found a greater odds of food insecurity among households with a yearly income of <$50,000 (odds ratio = 4.30 [95% confidence interval = 2.07 to 8.92], P < 0.001), tobacco use (2.33 [1.26 to 4.28], P = 0.007), Medicaid or no insurance (2.34 [1.19 to 4.62], P = 0.014), and Hispanic or Latino ethnicity (4.55 [1.69 to 12.24], P = 0.003), for each 10-year decrease in age (1.19 [1.00 to 1.40], P = 0.045), multiple surgically treated fractures (2.41 [1.08 to 5.35], P = 0.031), and for each additional 15 minutes of travel time to the nearest grocery store (2.12 [1.37 to 3.26], P < 0.001). Conclusion: Food insecurity is common in the orthopaedic trauma population, and households with food insecurity are more likely to have low diet quality. Nutrition supplementation during the healing phase after trauma and referral to nutrition assistance programs has the potential to mitigate malnutrition and prevent negative outcomes resulting from food insecurity.

Hip dysplasia causes pathologic joint mechanics and can produce hip instability, leading to progressive joint degeneration and osteoarthritis. Weight-bearing computed tomography (WBCT) is an emerging technology that may enable quantification of femoral–acetabular displacement as an objective indicator of instability. To evaluate this potential, 10 patients indicated for periacetabular osteotomy to treat hip dysplasia and 10 healthy controls underwent two WBCT protocols. Participants were scanned in a neutral stance [weight-bearing (WB)] and again with the hip stressed in maximal external rotation (WB-stress), a position hypothesized to reproduce anterior instability. Clinical, nonweight-bearing computed tomography (CT) scans were available for patients with hip dysplasia. Congruency of the femoroacetabular joint space and position of the femoral head in the acetabulum were quantified via multiple 2D manual measurements and automated 3D measurements. There were no 2D measurements found to differ between the WB and WB-stress scans in either dysplastic (P = .742–1.000) or control (P = .203–1.000) hips. 3D translation of the femoral head center from WB to WB-stress averaged 1.3 ± 0.6 mm in the control hips, compared to 0.9 ± 0.4 mm in the dysplastic hips (P = .096). 3D joint space width (JSW) was determined for both the control and dysplastic hips, with greater JSW found in control hips for both the WB (P = .049) and WB-stress (P = .003) scans. WBCT has the potential to better capture subtle femoral–acetabular displacement derived from both automated 3D and manual 2D measurements in static instability-prone joint orientations.