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Previous studies have attempted to characterize patellar morphology and its relation to patellofemoral osteoarthritis but have utilized relatively small samples. We designed a large-scale cadaveric analysis to elucidate any potential relationship. Patellar morphology in 1,032 patellae was characterized using patellar facet concavity patterns initially developed by Wiberg and using the ratio of the lateral and medial facet lengths. Patellofemoral arthritis grading for specimens was previously completed based primarily on osteophytic burden. The average age at time of death was 56 ± 10 years. Wiberg's grading returned kappa values of 0.43 for intrarelator reliability and 0.27 for interrelator reliability. Using multiple regression analysis, Wiberg's type II was found to be correlated with patellofemoral arthritis (p = 0.003). Lateral to medial facet ratio measurements returned intraclass coefficients of 0.91 for intrarelator reliability and 0.85 for interrelator reliability. There was no association between lateral to medial facet ratio and osteoarthritis. Regression analysis between Wiberg's typing and lateral-to-medial ratio (L:M) resulted in a coefficient of determination of 0.14. To our knowledge, this is the largest study evaluating the relationship between patellar morphology and arthritis. Although there was a relationship between Wiberg's type II and patellofemoral arthritis, the Wiberg systems was not easily reproducible in our study and returned a correlation with arthritis different then anatomically expected. A more reproducible system of lateral to medial facet ratio was investigated but did not find an association with arthritic changes. Given these findings, we did not find a patella morphology grading system which is both reliable and valid in regard to association with patellofemoral arthritis.

Background Analyses of skin cancer procedures adjusted for population changes are needed. Objective To describe trends in skin cancer–related biopsies and procedures in Medicare beneficiaries. Methods An ecological study of Medicare claims for skin biopsies and skin cancer procedures in 2000 to 2015. Results Biopsies increased 142%, and skin cancer procedures increased 56%. Mohs micrographic surgery (MMS) utilization increased on the head/neck, hands/feet, and genitalia (increasing from 11% to 27% of all treatment procedures) but was low on the trunk/extremities (increasing from 1% to 4%). Adjusted for increased Medicare enrollment (+36%) between 2000 and 2015, the number of biopsies and MMS procedures performed per 1000 beneficiaries increased (from 56 to 99 and from 5 to 15, respectively), whereas the number of excisions and destructions changed minimally (from 18 to 16 and from 19 to 18, respectively). Growth in biopsies and MMS procedures slowed between each time period studied: 4.3 additional biopsies per year and 0.9 additional MMS procedures per year per 1000 beneficiaries between 2000 and 2007, 2.2 and 0.5 more between 2008 and 2011, and 0.5 and 0.3 more between 2012 and 2015, respectively. Limitations Medicare claims–level data do not provide patient-level or nonsurgical treatment information. Conclusions The increased number of skin cancer procedures performed was largely the result of Medicare population growth over time. MMS utilization increased primarily on high- and medium-risk and functionally and cosmetically significant locations where tissue sparing and maximizing cure are critical.

OBJECTIVE To calculate the revenue generated for injury- and noninjury-related services after the initial injury event in an orthopaedic trauma population. DESIGN Retrospective cohort study. SETTING Single Level 1 trauma center. PARTICIPANTS Four hundred forty adult trauma patients treated operatively for spine, pelvis, and/or upper or lower extremity fractures with ≥1 night stay. INTERVENTION Operative fracture management. MAIN OUTCOME MEASUREMENT Revenue for follow-up care and for noninjury-related indications for 24 months. RESULTS Most patients returned for follow-up (92.3%), generating 6704 visits with professional and technical collections of $8,135,022 and $37,292,722, respectively, per 1000 unique patients. The greatest revenue was from rehabilitation services. Patients were less likely to return if they resided outside adjacent counties [odds ratio (OR) = 0.16], experienced a complication (OR = 0.38), or were older (OR per 10-year increase: 0.66) (all P < 0.0001). More than 70% of trauma patients were new to our system, accounting for 33% of all subsequent noninjury-related visits, most for primary care (25.6%). Male patients [OR = 3.28, 95% confidence interval (CI), 1.08-9.93], nonwhites (OR = 3.41; 95% CI, 1.41-8.28), and patients residing near the trauma center (OR = 16.1, 95% CI, 2.13-121) were more likely to return (P < 0.0001). Realized noninjury-related professional and technical revenue was $506 per operative orthopaedic trauma case. CONCLUSIONS Demographics and outcomes predict likelihood of follow-up. Rehabilitation services account for the greatest revenue per patient. The greatest number of return visits was for primary care services; awareness of such services, especially in men and in those residing near the hospital system, could improve retention.

Disorders of the patellofemoral joint are common. Diagnosis and management often involves the use tangential imaging of the patella and trochlear grove, with the sunrise projection being the most common. However, imaging protocols vary between institutions, and limited data exist to determine which radiographic projections provide optimal visualization of the trochlear groove at its deepest point. Plain radiographs of 48 cadaveric femora were taken at various beam-femur angles and the maximum trochlear depth was measured; a tilt-board apparatus was used to elevate the femur in 5-degree increments between 40 and 75 degrees. A corollary experiment was undertaken to investigate beam-femur angles osteologically: digital representations of each bone were created with a MicroScribe digitizer, and trochlear depth was measured on all specimens at beam-femur angles from 0 to 75 degrees. The results of the radiographic and digitizer experiments showed that the maximum trochlear grove depth occurred at a beam-femur angle of 50 degrees. These results suggest that the optimal beam-femur angle for visualizing maximum trochlear depth is 50 degrees. This is significantly lower than the beam-femur angle of 90 degrees typically used in the sunrise projection. Clinicians evaluating trochlear depth on sunrise projections may be underestimating maximal depth and evaluating a nonarticulating portion of the femur.

To characterize the charges and collections associated with the initial inpatient management of trauma patients who undergo operative fracture management.Retrospective.Level 1 trauma center.Four hundred forty consecutive, adult, trauma patients.Fixation for fracture of the spine, pelvis, acetabulum, and/or femur fractures.Professional and technical (facility) charges and collections from the initial inpatient management and 6 months of subsequent related care.Patients were predominantly male (74.3%) and white (63.2%) with a mean age of 41 years and mean injury severity score of 18.5. Uninsured (self-pay) patients represented the largest payer class (35.0%), and 34.5% of all patients were unemployed. Professional and technical charges totaled US $12,382,028 (US $28,140/patient) and US $39,682,225 (US $90,187/patient), respectively. Injury severity score, longer lengths of stay (LOS), and the presence of a complication were positive predictors of initial charges (P0.0001; adjusted R = 0.799). Professional and technical collections totaled US $2,418,096 (US $5,496/patient) and US $16,921,959 (US $38,459/patient) (percent of charge: 21.5% vs. 41.3%; P0.0001). Of the self-pay patients, 34.4% had no collections, resulting in potential lost revenue of US $2,513,988. Greater collections were predicted to occur in females, employed patients, and those with insurance (P0.0001; adjusted R = 0.35).Trauma patients often present without insurance, which compromises hospital revenue. Expectedly, charges are higher in more severely injured patients, those with longer LOS, and those experiencing complications. A bundled model will proportionately decrease reimbursements for a given episode of care in the event of longer LOS or occurrence of complications.

Patellofemoral joint osteoarthritis is common, although circumstances dictating its evolution and pathogenesis remain unclear. Advances in surgical technique have improved the ability to modify long-bone alignment in the coronal, sagittal, and axial planes. However, to our knowledge, there is no significant long-term data available in regard to the relationship between anatomic alignment parameters most amenable to surgical modification and patellofemoral joint osteoarthritis.Five-hundred and seventy-one cadaveric skeletons were obtained from the Hamann-Todd osteological collection. Mechanical lateral distal femoral angle, medial proximal tibial angle, tibial slope, femoral version, tibial torsion, the position of the tibial tubercle relative to the width of the tibial plateau, trochlear depth, and patellar size were measured using validated techniques. A previously published grading system for patellofemoral joint arthritis was used to quantify macroscopic signs of degenerative joint disease.Increasing age (standardized beta 0.532, p0.001), female gender (standardized beta 0.201, p=0.002), and decreasing mechanical lateral distal femoral angle (standardized beta -0.128, p=0.025) were independent correlates of increased patellofemoral joint osteoarthritis. A relatively more laterally positioned tibial tubercle trended towards predicting patellofemoral joint osteoarthritis (standardized beta 0.080, p=0.089).These findings confirm that patellofemoral joint osteoarthritis is strongly associated with increasing age and female gender. Valgus alignment of the distal femur, a relatively more lateral location of the tibial tubercle, and a shallower trochlear grove appear to have modest effects on the development of patellofemoral joint osteoarthritis.

Background Temporal analyses of skin cancer costs are needed to examine how expenditure differences between diagnoses are changing. Objective To tabulate the costs of skin cancer–related care (SCRC), including both screening and treatment, at an academic cancer center at 2 time points. Methods Cost data (insurance and patient payments) at an academic cancer center from 2008 and 2013 were queried for International Classification of Diseases, Ninth Revision, codes pertaining to skin cancer. Screening costs were separated from treatment costs through associated Current Procedural Terminology codes. Results The total annual cost of SCRC increased by 64%, the number of patients receiving SCRC increased by 45%, and the mean cost per patient treated increased by 13%. Screening accounted for 17% and 16% of total annual costs in 2008 and 2013, respectively. The mean cost per patient with melanoma increased by 84%, which was the largest increase among skin cancer diagnoses. In 2013, the few patients with melanoma who were treated with ipilimumab (n = 48 [4% of patients with melanoma]) accounted for 42% of melanoma treatment costs and 20% of SCRC costs. Limitations Prescription costs were unavailable. Conclusions Melanoma costs have increased as a result of the introduction of ipilimumab. Ongoing studies are needed to monitor the cost-effectiveness of SCRC at a national level.

To determine whether fructose-1,6-diphosphate (FDP) pretreatment can attenuate acute lung injury induced by ischemia-reperfusion in our isolated lung model in rats.Randomized, controlled study.Animal care facility procedure room.Twenty-four adult male Sprague-Dawley rats each weighing 250-350 g.Typical acute lung injury in rats was induced successfully by 10 mins of hypoxia followed by 75 mins of ischemia and 50 mins of reperfusion. Ischemia-reperfusion significantly increased microvascular permeability as measured by the capillary filtration coefficient, lung weight gain, lung weight to body weight ratio, pulmonary arterial pressure, and protein concentration of bronchoalveolar lav-age fluid.Pretreatment with FDP significantly attenuated the acute lung injury induced by ischemia-reperfusion as shown by a significant decrease in all of the assessed variables (p.05 p.001). The protective effect of FDP was nearly undetectable when promazine (an ecto-adenosine 5-triphosphatase inhibitor) was added before FDP pretreatment.Pretreatment with FDP significantly ameliorates acute lung injury induced by ischemia-reperfusion in rats.

Objective: To determine whether the lipophilic antioxidant U-74389G can ameliorate the acute lung injury induced by phorbol myristate acetate (PMA) in our isolated lung model in rats, and to compare its activity with the intracellular enzymes superoxide dismutase (SOD) or catalase. Design: Randomized, controlled study. Setting: Animal-care facility procedure room. Subjects: Forty-two adult male Sprague-Dawley rats each weighing 250-350 g. Interventions: Typical acute lung injury was induced successfully by PMA during 60 mins of observation. PMA (2 μg/kg) elicited a significant increase in microvascular permeability (measured by using the capillary filtration coefficient K fc ), lung weight gain, the lung weight/body weight ratio, pulmonary arterial pressure, and the protein concentration of the bronchoalveolar lavage fluid. Measurements and Main Results: Pretreatment with 1 mg of U-74389G significantly attenuated the acute lung injury induced by PMA, all parameters having decreased significantly (p

BACKGROUND AND METHODS The protective effects of dimethylthiourea, a potent scavenger of hydroxy radical (.OH) and hydrogen peroxide, in experimental lung injury in large animals remain controversial. The present study was designed to determine whether dimethylthiourea can ameliorate the acute lung injury produced in dogs by phorbol myristate acetate. Six dogs were infused with dimethylthiourea (0.75 g/kg in saline) for 1.5 hrs, beginning 1 hr before an i.v. bolus injection of phorbol myristate acetate (17 micrograms/kg); six dogs received phorbol myristate acetate (17 micrograms/kg) alone; and six dogs were infused with saline alone. Hemodynamic changes, arterial oxygenation, and the development of lung edema were monitored for 4 hrs after phorbol myristate acetate injection to assess the extent of lung damage. RESULTS As compared with the dogs that received phorbol myristate acetate alone, the edematous lung damage was significantly reduced in those dogs that received dimethylthiourea as well as phorbol myristate acetate. In the dimethylthiourea-treated dogs, the lung wet/dry weight ratios were smaller (p less than .01); protein concentrations in lung lavage fluid were lower (p less than .01); the decrease in PaO2 was significantly reduced (p less than .01); and there were significant reductions in the alveolar-arterial oxygen tension difference (P[A-a]O2) (p less than .01) and shunt (Qsp/Qt) (p less than .05). Also, dimethylthiourea significantly lowered the increased mean pulmonary arterial pressure levels during the second half of the experiment. CONCLUSIONS These experimental data suggest that dimethylthiourea is capable of reducing the neutrophil-mediated lung injury produced by the release of hydroxy radical and/or hydrogen peroxide in dogs exposed to phorbol myristate acetate.