Background Risk adjustment has implications across orthopaedics, including informing clinical care, improving payment models, and enabling observational orthopaedic research. Although comorbidity indices (such as the American Society of Anesthesiologists [ASA] classification, Charlson comorbidity index [CCI], and Elixhauser comorbidity index [ECI]) have been examined extensively in the immediate perioperative period, there is a dearth of data on their three-way comparative effectiveness and long-term performance. Moreover, the discriminative ability of the CCI and ECI after orthopaedic surgery has not been validated in the ICD-10 era, despite new diagnosis codes from which they are calculated. Question/purpose Which comorbidity index (ASA, CCI, or ECI) is associated with the greatest accuracy on receiver operating curve (ROC) analysis with respect to the endpoint of death at 90 days and 1 year after hip fracture surgery in the ICD-10 era? Methods A retrospective study was conducted on all patients undergoing surgical fixation of primary hip fractures at two Level I trauma centers and three community hospitals from October 2016 to May 2019. This time frame allowed for a 1-year baseline period of ICD-10 data to assess comorbidities and at least a 1-year follow-up period to assess mortality. Initially 1516 patients were identified using Common Procedural Terminology and ICD codes, of whom 4% (60 of 1516) were excluded after manual review; namely, those with pathologic fractures (n = 38), periprosthetic fractures (n = 12), and age younger than 18 years (n = 10). Of the patients who were studied, 69% (998 of 1456) were women and the mean ± SD age was 77 ± 14 years; 45% (656 of 1456) were treated with intramedullary nails, 32% (464 of 1456) underwent hemiarthroplasties, 10% (149 of 1456) underwent THAs, 7% (104 of 1456) underwent percutaneous fixations, and 6% (83 of 1456) were treated with plates and screws. The mean ± SD ASA score was 2.8 ± 0.6, CCI was 3.1 ± 3.2, and ECI was 5.2 ± 3.5. Hip fracture fixation was chosen as the operation of interest given the high incidence of this injury, the well-documented effects of comorbidities on complications, and the critical importance of risk stratification and perioperative medical management for these patients. Demographics, comorbidities, surgical details, as well as 90-day and 1-year mortality were collected. Logistic regressions with ROC curves were used to determine the accuracy and comparative effectiveness of the three measures. The 90-day mortality rate was 7.4%, and the 1-year mortality rate was 15.0%. Results The accuracy (area under the curve [AUC]) for 1-year mortality was 0.685 (95% CI 0.656 to 0.714) for the ASA, 0.755 (95% CI 0.722 to 0.788) for the ECI, and 0.769 (95% CI 0.739 to 0.800) for the CCI. The CCI and ECI were more accurate than ASA (p < 0.001 for both), while the CCI and ECI did not differ (p = 0.30). The ECI (AUC 0.756 [95% CI 0.712 to 0.800]) was more accurate for 90-day mortality than the ASA (AUC 0.703 [95% CI 0.663 to 0.744]; p = 0.04), while CCI (AUC 0.742 [95% CI 0.698 to 0.785]) with ASA (p = 0.17) and CCI with ECI (p = 0.46) did not differ at 90 days. Conclusion Performance measures and research results may vary depending on what comorbidity index is used. We found that the CCI and ECI were more accurate than the ASA score for 1-year mortality after hip fracture surgery. Moreover, these data validate that the CCI and ECI can perform reliably in the ICD-10 era. If other studies from additional practice settings confirm these findings, as would be expected because of the objective nature of these indices, the CCI or ECI may be a useful preoperative measure for surgeons to assess 1-year mortality for hip fracture patients and should likely be used for institutional orthopaedic research involving outcomes 90 days and beyond. Level of Evidence Level III, diagnostic study.

We previously showed that infants born with long-gap esophageal atresia (LGEA) demonstrate clinically significant brain MRI findings following repair with the Foker process. The current pilot study sought to identify any pre-existing (PRE-Foker process) signs of brain injury and to characterize brain and corpus callosum (CC) growth. Preterm and full-term infants (n = 3/group) underwent non-sedated brain MRI twice: before (PRE-Foker scan) and after (POST-Foker scan) completion of perioperative care. A neuroradiologist reported on qualitative brain findings. The research team quantified intracranial space, brain, cerebrospinal fluid (CSF), and CC volumes. We report novel qualitative brain findings in preterm and full-term infants born with LGEA before undergoing Foker process. Patients had a unique hospital course, as assessed by secondary clinical end-point measures. Despite increased total body weight and absolute intracranial and brain volumes (cm3) between scans, normalized brain volume was decreased in 5/6 patients, implying delayed brain growth. This was accompanied by both an absolute and relative CSF volume increase. In addition to qualitative findings of CC abnormalities in 3/6 infants, normative CC size (% brain volume) was consistently smaller in all infants, suggesting delayed or abnormal CC maturation. A future larger study group is warranted to determine the impact on the neurodevelopmental outcomes of infants born with LGEA.

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Iron serves as a critical cofactor for proteins involved in a host of biological processes. In most animals, dietary iron is absorbed in enterocytes and then disseminated for use in other tissues in the body. The brain is particularly dependent on iron. Altered iron status correlates with disorders ranging from cognitive dysfunction to disruptions in circadian activity. The exact role iron plays in producing these neurological defects, however, remains unclear. Invertebrates provide an attractive model to study the effects of iron on neuronal development since many of the genes involved in iron metabolism are conserved, and the organisms are amenable to genetic and cytological techniques. We have examined synapse growth specifically under conditions of iron deficiency in the Drosophila circadian clock circuit. We show that projections of the small ventrolateral clock neurons to the protocerebrum of the adult Drosophila brain are significantly reduced upon chelation of iron from the diet. This growth defect persists even when iron is restored to the diet. Genetic neuronal knockdown of ferritin 1 or ferritin 2, critical components of iron storage and transport, does not affect synapse growth in these cells. Together, these data indicate that dietary iron is necessary for central brain synapse formation in the fly and further validate the use of this model to study the function of iron homeostasis on brain development.

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Background: Considering the lengthy recovery and high recurrence risk after a hamstring injury, effective rehabilitation and accurate prognosis are fundamental to timely and safe return to play (RTP) for athletes. Purpose: To analyze methods of rehabilitation for acute proximal and muscular hamstring injuries and summarize prognostic factors associated with RTP. Study Design: Systematic review; Level of evidence, 4. Methods: In August 2020, MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, and SPORTDiscus were queried for studies examining management and factors affecting RTP after acute hamstring injury. Included were randomized controlled trials, cohort studies, case-control studies, and case series appraising treatment effects on RTP, reinjury rate, strength, flexibility, hamstrings-to-quadriceps ratio, or functional assessment, as well as studies associating clinical and magnetic resonance imaging factors with RTP. Risk of bias was assessed using the Cochrane Risk-of-Bias Tool for Randomized Trials or the Methodological Index for Non-Randomized Studies (MINORS). Results: Of 1289 identified articles, 75 were included. The comparative and noncomparative studies earned MINORS scores of 18.8 ± 1.3 and 11.4 ± 3.4, respectively, and 12 of the 17 randomized controlled trials exhibited low risk of bias. Collectively, studies of muscular injury included younger patients and a greater proportion of male athletes compared with studies of proximal injury. Surgery for proximal hamstring ruptures achieved superior outcomes to nonoperative treatment, whereas physiotherapy incorporating eccentric training, progressive agility, and trunk stabilization restored function and hastened RTP after muscular injuries. Platelet-rich plasma injection for muscular injury yielded inconsistent results. The following initial clinical findings were associated with delayed RTP: greater passive knee extension of the uninjured leg, greater knee extension peak torque angle, biceps femoris injury, greater pain at injury and initial examination, “popping” sound, bruising, and pain on resisted knee flexion. Imaging factors associated with delayed RTP included magnetic resonance imaging-positive injury, longer lesion relative to patient height, greater muscle/tendon involvement, complete central tendon or myotendinous junction rupture, and greater number of muscles injured. Conclusion: Surgery enabled earlier RTP and improved strength and flexibility for proximal hamstring injuries, while muscular injuries were effectively managed nonoperatively. Rehabilitation and athlete expectations may be managed by considering several suitable prognostic factors derived from initial clinical and imaging examination.

Study Design. Retrospective analysis on prospectively collected data. Objective. The purposes of this study were to (1) assess disparities in relative utilization of outpatient cervical spine surgery between White and Black patients from 2010 to 2019 and (2) to measure how these racial differences have evolved over time. Summary of Background Data. Although outpatient spine surgery has become increasingly popularized over the last decade, it remains unknown how racial disparities in surgical utilization have translated to the outpatient setting and whether restrictive patterns of access to outpatient cervical spine procedures may exist. Methods. A retrospective cohort study from 2010 to 2019 was conducted using the National Surgical Quality Improvement Program database. Relative utilization of outpatient (same-day discharge) for anterior cervical discectomy and fusion (OP-ACDF) and cervical disk replacement (OP-CDR) were assessed and trended over time between races. Multivariable regressions were subsequently utilized to adjust for baseline patient factors and comorbidities. Results. Overall, Black patients were significantly less likely to undergo OP-ACDF or OP-CDR surgery when compared with White patients (P<0.03 for both OP-ACDF and OP-CDR). From 2010 to 2019, a persisting disparity over time was found in outpatient utilization for both ACDF and CDR (e.g. White vs. Black OP-ACDF: 6.0% vs. 3.1% in 2010 compared with 16.7% vs. 8.5% in 2019). These results held in all adjusted analyses. Conclusions. To our knowledge, this is the first study reporting racial disparities in outpatient spine surgery and demonstrates an emerging disparity in outpatient cervical spine utilization among Black patients. These restrictive patterns of access to same-day outpatient hospital and surgery centers may contribute to broader disparities in the overall utilization of major spine procedures that have been previously reported. Renewed interventions are needed to both understand and address these emerging inequalities in outpatient care before they become more firmly established within our orthopedic and neurosurgery spine delivery systems.