Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

SummaryCopper and zinc are essential trace biometals that regulate cardiovascular homeostasis, and dysregulation of these metals has been linked to vascular diseases, including hypertension. In this article, we review recent human population studies concerning this topic, focusing on: 1) the relationship between blood pressure and levels of zinc and copper; 2) correlations between trace metals, the renin-angiotensin system, obesity, and hypertension; 3) the relationship between environmental metal pollution and the development of hypertension; and 4) methods commonly employed to assay zinc and copper in human specimens. Moreover, based on the findings of these studies, we suggest the following topics as the basis for future investigations: 1) the potential role of environmental metal pollution as a causal factor for hypertension; 2) metal profiles within specific pathogenic subsets of patients with hypertension; 3) standardizing the experimental design so that the results between different studies are more comparable; and 4) the requirement for animal experiments as complementary approaches to address mechanistic insight that cannot be studied in human populations.

PurposeOutcomes are excellent following surgical management of displaced supracondylar humerus fractures. Short delays until surgical fixation have been shown to be equivalent to immediate fixation with regards to complications. We hypothesized that insurance coverage may impact access to care and the patient’s ability to return to the operating room for outpatient surgery.MethodsA retrospective review of supracondylar humerus fractures treated at a large urban pediatric hospital from 2008 to 2012 was performed. Fractures were classified by the modified Gartland classification and baseline demographics were collected. Time from discharge to office visits and subsequent surgical fixation was calculated for all type II fractures discharged from the emergency department. Insurance status and primary carrier were collected for all patients.Results2584 supracondylar humerus fractures were reviewed, of which 584 were type II fractures. Of the 577 type II fractures with complete records, 383 patients (61 %) were admitted for surgery and the remaining 194 were discharged with plans for outpatient follow-up. There was no difference in insurance status between patients admitted for immediate surgery. Of the 194 patients who were discharged with type 2 fractures after gentle reduction, 59 patients (30.4 %) ultimately underwent surgical fixation. Of these, 42 patients were privately insured (58.3 % of patients with private insurance), 16 had governmental insurance (15.1 %), and 1 was uninsured (6.3 %). Patients with private insurance were 2.46 times more likely to have surgery than patients with public or no insurance (p = 0.005). Of the 135 patients who did not eventually have surgery, 92 (68.1 %) were seen in the clinic. Patients with private insurance were 2.78 times more likely to be seen back in the clinic when compared to publicly insured or uninsured patients (p = 0.0152).ConclusionsDespite an equivalent number of privately insured and publicly insured patients undergoing immediate surgery for type II fractures, those with public or no insurance who were discharged were 2.46 times less likely to obtain outpatient surgery when compared to privately insured patients. Patient insurance status and the ability to follow up in a timely manner should be assessed at the time of initial evaluation in the emergency department.Level of evidence Level 3

Therapeutic, IV.

Blount disease is an acquired, asymmetrical disorder of proximal tibial growth that results in a complex three-dimensional proximal tibial deformity, with tibial varus being the dominating feature. Although the exact pathophysiology is unknown, Blount disease is separated into 2 clinical variants, infantile and adolescent, based on the onset of symptoms occurring before or after the age of 10 years. If recognized and treated early, affected patients generally have a favorable prognosis; however, if neglected, it can lead to progressive malalignment and premature osteoarthritis. We present a patient with bilateral neglected Blount disease who underwent successful bilateral total knee arthroplasty performed in a staged fashion using a gap balancing technique with constrained condylar knee implants.

No abstract

Replacement (HOOS, JR.) and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR.) were collected at 1 month prior to surgery, 6 weeks, 12 weeks, and 1 year postoperatively. Patients were compared based on how many days within the first 10 postoperative days they utilized EPRA. RESULTS: 1,865 patients undergoing THA and 875 patients undergoing TKA were registered for EPRA. THA patients who logged in to EPRA 6 or more of the first 10 postoperative days reported significantly better HOOS, JR. scores at 12 weeks compared to those who did not log in or logged in only 1-5 days (p = 0.033 and p = 0.030, respectively). TKA patients who logged in to EPRA 6 or more of the first 10 postoperative days trended towards better KOOS, JR. scores at all postoperative timepoints, but these findings did not reach significance. CONCLUSION: Our data suggests that patients who engage early and frequently with EPRA may have increased PROMs after TJA. These findings support EPRA as a value-based tool for TJA rehabilitation and emphasize the importance of preoperative patient education for maximizing postoperative PROMs.