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The continuing escapades of Uncle, the unimaginably rich elephant, as he struggles to defend his vast ramshackle castle against the onslaught of the scruffy Badford Crowd from the dingy fortress across the way.

Introduction Total femur replacement (TFR) is a salvage procedure for patients with multiple failed hip and knee arthroplasties and is associated with high complication rates. Intramedullary TFR has emerged as a technique to preserve critical soft tissue attachments; however, maintaining limb length, alignment, and rotation remains challenging. Case Presentation We describe a novel case of intramedullary TFR utilizing external fixation to address these technical challenges. A 64-year-old male with subsidence of a hinged knee tumor prosthesis to the level of the greater trochanter underwent intramedullary TFR. External fixation was applied to the residual femoral and tibial bones to maintain limb length, alignment, and rotation during revision knee arthroplasty and total hip arthroplasty. At 1-year follow-up, the patient demonstrated improved function without complication or infection. Conclusion Based on this case report, intramedullary TFR utilizing external fixation can be used to maintain critical aspects of the limb, such as neurovascular structures, soft tissues, and positioning the lower extremity, therefore easing many of the technical challenges of the procedure. This may allow for fewer surgical complications as the difficulty of the procedure is eased and better patient outcomes as the procedure may be completed with more precision. Keywords: external fixation, intramedullary femur replacement, total femur replacement

Prosthetic joint infection (PJI) is a high‐cost and high‐morbidity complication of total joint arthroplasty accounting for about 1%–2% of all joint replacements. Rarely, a fungal pathogen may cause coinfection or superinfection and complicate treatment. Fungal PJI is associated with higher morbidity and a lower rate of clearance of infection, with rates as low as 50% or less in the literature. Intra‐articular antibiotics as a treatment for PJI may be a promising intervention for challenging PJIs. We present a novel case utilizing voriconazole via intra‐articular catheters with successful clearance of a recalcitrant fungal prosthetic joint infection with 2 years' follow‐up. A detailed case study and protocol is presented for a 71‐year‐old male patient who failed two 2‐stage revision arthroplasties for complicated and recalcitrant fungal PJI. The patient was indicated for intra‐articular administration of antifungal medication. A two‐stage, both‐component knee revision with placement of two indwelling intra‐articular catheters was performed. Subsequently, voriconazole was administered daily for 6 weeks in alternating catheters. After completion of antifungal treatment, the catheters were removed in clinic. The patient demonstrates no evidence of infection after 2 years with a return to baseline function. To our knowledge, this is the first case in which intra‐articular voriconazole is administered through indwelling catheters of the knee. We demonstrate successful clearance of a complex and recalcitrant fungal PJI using this novel treatment. Intra‐articular use of voriconazole may be an option for patients with fungal PJI.

Debridement of the bone surface during a surgical fusion procedure initiates an injury response promoting a healing cascade of molecular mediators released over time. Autologous grafts offer natural scaffolding to fill the bone void and to provide local bone cells. Commercial bone grafting products such as allografts, synthetic bone mineral products, etc., are used to supplement or to replace autologous grafts by supporting osteoinductivity, osteoconductivity, and osteogenesis at the surgical site. To assure osteogenic potential, preservation of allogeneic cells with cryoprotectants has been developed to allow for long-term storage and thus delivery of viable bone cells to the surgical site. Dimethyl sulfoxide (DMSO) is an intracellular cryoprotectant commonly used because it provides good viability of the cells post-thaw. However, there is known cytotoxicity reported for DMSO when cells are stored above cryogenic temperatures. For most cellular bone graft products, the cryoprotectant is incorporated with the cells into the other mineralized bone and demineralized bone components. During thawing, the DMSO may not be sufficiently removed from allograft products compared to its use in a cell suspension where removal by washing and centrifugation is available. Therefore, both the allogeneic cell types in the bone grafting product and the local cell types at the bone grafting site could be affected as cytotoxicity varies by cell type and by DMSO content according to reported studies. Overcoming cytotoxicity may be an additional challenge in the formation of bone at a wound or surgical site. Other extracellular cryoprotectants have been explored as alternatives to DMSO which preserve without entering the cell membrane, thereby providing good cellular viability post-thaw and might abrogate the cytotoxicity concerns.

Bone disorders can have a devastating impact on an individual’s quality of life. The main objective of our study was to analyze various demographic disparities between various bone disorders in the demographically unique Rio Grande Valley region. We hypothesized that osteoporosis would be the most prevalent condition and that the demographics between the various conditions would vary depending on age, sex, BMI, and ethnicity but not on marital status. This was a retrospective chart review using the University of Texas Rio Grande Valley UTHealth electronic database from January 1, 2017, to January 1, 2024. Any relevant individuals seen at a UTRGV affiliated institution were included. We analyzed medical charts, via ICD‐10 codes, of individuals who were diagnosed with osteoporosis, osteomalacia, rickets, Paget bone disease, and osteonecrosis. Bivariate and binary logistic regression analyses were performed to analyze the data. Hispanic ethnicity showed a decreased risk of bone disorder (estimate = −0.2814), bordering on significance ( p = 0.053). Female participants had significantly higher odds of bone disorder (estimate = 0.7861, p < 0.001). Obese individuals (estimate = −0.7837, p < 0.001) and overweight individuals had lower odds (estimate = −0.3328, p = 0.047) of bone disorder. Underweight individuals showed higher odds of bone disorder (estimate = 0.9605, p = 0.002). The odds of bone disorder increased with age (estimate = 0.0581, p < 0.001). Our results increase the knowledge of orthopedics in this region, and specifically, the bone disorders are discussed. The results may also allow physicians to better identify at‐risk individuals in this community and others alike to improve the management of bone disorders. This study warrants further research on at‐risk demographics to further improve the orthopedic knowledge and care of medically underserved individuals.

Understanding of SARS-CoV-2 infection in US children has been limited by the lack of large, multicenter studies with granular data. To examine the characteristics, changes over time, outcomes, and severity risk factors of children with SARS-CoV-2 within the National COVID Cohort Collaborative (N3C). A prospective cohort study of encounters with end dates before September 24, 2021, was conducted at 56 N3C facilities throughout the US. Participants included children younger than 19 years at initial SARS-CoV-2 testing. Case incidence and severity over time, demographic and comorbidity severity risk factors, vital sign and laboratory trajectories, clinical outcomes, and acute COVID-19 vs multisystem inflammatory syndrome in children (MIS-C), and Delta vs pre-Delta variant differences for children with SARS-CoV-2. A total of 1 068 410 children were tested for SARS-CoV-2 and 167 262 test results (15.6%) were positive (82 882 [49.6%] girls; median age, 11.9 [IQR, 6.0-16.1] years). Among the 10 245 children (6.1%) who were hospitalized, 1423 (13.9%) met the criteria for severe disease: mechanical ventilation (796 [7.8%]), vasopressor-inotropic support (868 [8.5%]), extracorporeal membrane oxygenation (42 [0.4%]), or death (131 [1.3%]). Male sex (odds ratio [OR], 1.37; 95% CI, 1.21-1.56), Black/African American race (OR, 1.25; 95% CI, 1.06-1.47), obesity (OR, 1.19; 95% CI, 1.01-1.41), and several pediatric complex chronic condition (PCCC) subcategories were associated with higher severity disease. Vital signs and many laboratory test values from the day of admission were predictive of peak disease severity. Variables associated with increased odds for MIS-C vs acute COVID-19 included male sex (OR, 1.59; 95% CI, 1.33-1.90), Black/African American race (OR, 1.44; 95% CI, 1.17-1.77), younger than 12 years (OR, 1.81; 95% CI, 1.51-2.18), obesity (OR, 1.76; 95% CI, 1.40-2.22), and not having a pediatric complex chronic condition (OR, 0.72; 95% CI, 0.65-0.80). The children with MIS-C had a more inflammatory laboratory profile and severe clinical phenotype, with higher rates of invasive ventilation (117 of 707 [16.5%] vs 514 of 8241 [6.2%]; P < .001) and need for vasoactive-inotropic support (191 of 707 [27.0%] vs 426 of 8241 [5.2%]; P < .001) compared with those who had acute COVID-19. Comparing children during the Delta vs pre-Delta eras, there was no significant change in hospitalization rate (1738 [6.0%] vs 8507 [6.2%]; P = .18) and lower odds for severe disease (179 [10.3%] vs 1242 [14.6%]) (decreased by a factor of 0.67; 95% CI, 0.57-0.79; P < .001). In this cohort study of US children with SARS-CoV-2, there were observed differences in demographic characteristics, preexisting comorbidities, and initial vital sign and laboratory values between severity subgroups. Taken together, these results suggest that early identification of children likely to progress to severe disease could be achieved using readily available data elements from the day of admission. Further work is needed to translate this knowledge into improved outcomes.

Previously, we observed changes in the scale, rotation, and location of drawn shapes when subjects simultaneously performed a secondary task, but not in the shape or proportion of the drawing. We suggested the secondary task impacted motor planning and execution or proprioception of the primary task. To isolate for proprioceptive effects, here we used the same secondary task during passive shape perception. A robotic manipulandum moved the subject’s hand around the perimeter of a template shape and then a test shape differing in size, proportion, or location. Subjects also performed the same primary task while simultaneously performing a secondary task of reporting the orientation of right or left tilted arrows. We compared the performance between single and dual task, and different workspaces. In single-task conditions, subjects perceived scale, location, and proportion very close to the actual (all biases under 1 cm). A secondary task only increased the uncertainty range for judgment of scale, with no other effect. Subjects judged shapes in the centered workspace to be smaller and closer relative to the template compared with those in the peripheral workspace, although in that workspace, it was more difficult to discern changes in the proportion of the shape. The result for scale in the current passive paradigm is not different from our active study in which efference copy was available. This suggests that the scale parameters of the shape, whether actively or passively encountered, are disrupted by task interference at the level of proprioception or sensory integration rather than motor planning and execution.

Each year, the U.S. NHANES measures hundreds of chemical biomarkers in samples from thousands of study participants. These biomarker measurements are used to establish population reference ranges, track exposure trends, identify population subsets with elevated exposures, and prioritize research needs. There is now interest in further utilizing the NHANES data to inform chemical risk assessments. This article highlights a) the extent to which U.S. NHANES chemical biomarker data have been evaluated, b) groups of chemicals that have been studied, c) data analysis approaches and challenges, and d) opportunities for using these data to inform risk assessments. A literature search (1999-2013) was performed to identify publications in which U.S. NHANES data were reported. Manual curation identified only the subset of publications that clearly utilized chemical biomarker data. This subset was evaluated for chemical groupings, data analysis approaches, and overall trends. A small percentage of the sampled NHANES-related publications reported on chemical biomarkers (8% yearly average). Of 11 chemical groups, metals/metalloids were most frequently evaluated (49%), followed by pesticides (9%) and environmental phenols (7%). Studies of multiple chemical groups were also common (8%). Publications linking chemical biomarkers to health metrics have increased dramatically in recent years. New studies are addressing challenges related to NHANES data interpretation in health risk contexts. This article demonstrates growing use of NHANES chemical biomarker data in studies that can impact risk assessments. Best practices for analysis and interpretation must be defined and adopted to allow the full potential of NHANES to be realized.

Power- and signal- cable attachments have a significant impact on the vibrations of space structures. Recent works show the importance of having an analytical model to gain physical insight into the influence of cabling on the dynamics of host structures. The models in the literature focus mainly on pure bending vibrations and ignore the effect of coupling between different coordinates. Recently, the authors demonstrated the importance of modeling the coupling effects in cable-harnessed (CH) beams with straight and periodic wrapping patterns. In real-life situations, the cable attachment patterns are mostly non-periodic, and the cables are also attached to host structures that consist of a combination of several harness elements of same (homogenous) or different (non-homogenous) material properties. Hence, the fully coupled vibration model developed in this article is the first to analyze the vibrations of homogenous and non-homogenous CH beams with non-periodic wrapping patterns. The Frequency Response Functions (FRFs) of the developed model are compared with experiment FRFs in the case of the homogenous non-periodic wrapping pattern. The study shows that the coupling effects are pronounced in non-periodic wrapped CH beams, and the advantage of developing the coupled model over the decoupled model is shown through experimental validation.

Total joint arthroplasties, including total elbow arthroplasty (TEA), are growing in number and shifting toward a younger age group. These procedures are also moving more toward the outpatient setting compared to previous years. We are conducting this study to update and summarize the current knowledge about the outcomes of TEA in outpatient versus inpatient settings. We conducted a systematic review and meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework to compare TEA outcomes in outpatient versus inpatient settings. Electronic database searches were performed using PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Google Scholar. Previous studies deemed eligible for this study focused on inpatient cohorts and outpatient cohorts or compared inpatient and outpatient cohorts receiving TEA. All data used was obtained from the studies that were included. Three studies were deemed eligible and included a total of 1,634 patients, with 1,048 being inpatient and 586 being outpatient. There was a significant increase in total (any) complication rate (log of odds ratio (lnOR): 1.02, 95% CI: 0.35 to 1.68), adverse discharge (lnOR: 1.07, 95% CI: 0.22 to 1.92), and surgical site infection (lnOR: 0.88, 95% CI: 0.05 to 1.71) in the inpatient setting compared to the outpatient setting. There was no significant difference between outpatient and inpatient settings in regard to readmissions (lnOR: 0.85, 95% CI: -0.95 to 2.66), urinary tract infections (UTI)/renal complications (lnOR: 0.04, 95% CI: -0.09 to 0.17), pneumonia/respiratory failure (lnOR: 0.61, 95% CI: -0.29 to 1.51), deep vein thrombosis (DVT)/pulmonary embolism (lnOR: 0.07, 95% CI: -1.31 to 1.44), sepsis (lnOR: 0.86, 95% CI: -0.50 to 2.21), and wound dehiscence (lnOR: 0.55, 95% CI: -0.58 to 1.68). Our results reveal that with careful patient selection, current surgical techniques, and pain control methods, TEA may be performed in the outpatient setting with less risk of complications and lower financial burden compared to inpatient TEA.