Clinical Orthopaedics and Related Research

Clinical Orthopaedics and Related Research

Editorial: Are We All Better-than-Average Drivers, and Better-than-Average Kissers? Outwitting the Kruger–Dunning Effect in Clinical Practice and Research

01-10-2019 – Leopold, Seth S.

Journal Article

No abstract available

Editor’s Spotlight/Take 5: Do Skills Acquired from Training with a Wire Navigation Simulator Transfer to a Mock Operating Room Environment?

01-10-2019 – Leopold, Seth S.

Journal Article

No abstract available

Do Skills Acquired from Training with a Wire Navigation Simulator Transfer to a Mock Operating Room Environment?

01-10-2019 – Long, Steven A.; Thomas, Geb; Karam, Matthew D.; Anderson, Donald D.

Journal Article

Background Skills training and simulation play an increasingly important role in orthopaedic surgical education. The intent of simulation is to improve performance in the operating room (OR), a trait known as transfer validity. No prior studies have explored how simulator-based wire navigation training can transfer to higher-level tasks. Additionally, there is a lack of knowledge on the format in which wire navigation training should be deployed.
Questions/purposes (1) Which training methods (didactic content, deliberate practice, or proficiency-based practice) lead to the greatest improvement in performing a wire navigation task? (2) Does a resident’s performance using a wire navigation simulator correlate with his or her performance on a higher-level simulation task in a mock OR involving a C-arm, a radiopaque femur model, and a large soft tissue surrogate surrounding the femur?Methods Fifty-five residents from four different medical centers participated in this study over the course of 2 years. The residents were divided into three groups: traditional training (included first-year residents from the University of Iowa, University of Minnesota, and the Mayo Clinic), deliberate practice (included first-year residents from the University of Nebraska and the University of Minnesota), and proficiency training (included first-year residents from the University of Minnesota and the Mayo Clinic). Residents in each group received a didactic introduction covering the task of placing a wire to treat an intertrochanteric fracture, and this was considered traditional training. Deliberate practice involved training on a radiation-free simulator that provided specific feedback throughout the practice sessions. Proficiency training used the same simulator to train on specific components of wire navigation, like finding the correct starting point, to proficiency before moving to assessment. The wire navigation simulator uses a camera system to track the wire and provide computer-generated fluoroscopy. After training, task performance was assessed in a mock OR. Residents from each group were assessed in the mock OR based on their use of fluoroscopy, total time, and tip-apex distance. Correlation analysis was performed to examine the relationship between resident performance on the simulator and in the mock OR.
Results Residents in the two simulation-based training groups had a lower tip-apex distance than those in the traditional training group (didactic training tip-apex distance: 24 ± 7 mm, 95% CI, 20–27; deliberate practice tip-apex distance: 16 ± 5 mm, 95% CI, 13–19, p = 0.001; proficiency training tip-apex distance: 15 ± 4 mm, 95% CI, 13–18, p < 0.001). Residents in the proficiency training group used more images than those in the other groups (didactic training: 22 ± 12 images, p = 0.041; deliberate practice: 19 ± 8 images; p = 0.012, proficiency training: 31 ± 14 images). In the two simulation-based training groups, resident performance on the simulator, that is, tip-apex distance, image use, and overall time, was correlated with performance in the mock OR (r-square = 0.15 p = 0.030, 0.61 p < 0.001, and 0.43 p < 0.001, respectively).
Conclusions As residency programs are designing their curriculum to train wire navigation skills, emphasis should be placed on providing an environment that allows for deliberate practice with immediate feedback about their performance. Simulators such as the one presented in this study offer a safe environment for residents to learn this key skill.
Level of Evidence Level II, therapeutic study.

Not the Last Word: High-value Health Care and the Assassination of George Washington

01-10-2019 – Bernstein, Joseph

Journal Article

No abstract available

Medicolegal Sidebar: Getting Sued By Someone Else’s Patient—When Does a Curbside Consultation Carry Medicolegal Jeopardy?

01-10-2019 – Bal, B. Sonny; Teo, Wendy; Brenner, Lawrence H.

Journal Article

No abstract available

On Patient Safety: How Can Orthopaedic Surgeons Improve Patient Safety at Nursing Homes?

01-10-2019 – Rickert, James

Journal Article

No abstract available

CORR® Curriculum – Orthopaedic Education: Can Adopting Entrustable Professional Activities Improve How We Assess Our Residents?

01-10-2019 – Dougherty, Paul J.

Journal Article

No abstract available

A Day at the Office: How Private Practicing Orthopaedic Surgeons Grow Their Knowledge Base

01-10-2019 – Lundy, Douglas W.

Journal Article

No abstract available

Determining the Generalizability of the PROMIS Depression Domain’s Floor Effect and Completion Time in Patients Undergoing Orthopaedic Surgery

01-10-2019 – Bernstein, David N.; Atkinson, Joshua; Fear, Kathleen; Baumhauer, Judith F.; Mesfin, Addisu; Rubery, Paul T.; Hammert, Warren C.

Journal Article

Background Depression is common and can decrease the likelihood that a patient undergoing an orthopaedic procedure will improve after that intervention. Research at a single institution using the Patient-reported Outcomes Measurement Information System (PROMIS) showed that the PROMIS Depression domain had a substantial floor effect (lowest depressive symptoms measurable) in patients with orthopaedic conditions, although the instrument is designed to follow a population-based normal distribution. Patients with the lowest scores (floor) completed the questionnaire more quickly than those who did not have the lowest scores, which suggests that patients may not want to report or discuss depressive symptoms with their orthopaedic surgeon.
Questions/purposes (1) Do the scores of a large population of patients with orthopaedic conditions completing the PROMIS Physical Function (PF), Pain Interference (PI), and Depression questionnaires follow the normal population distribution used to calibrate the PROMIS instrument? (2) Do the scores of a large population of patients with foot and ankle, spine, upper extremity, multiple orthopaedic subspecialty, or other orthopaedic conditions completing the PROMIS Depression questionnaire follow the normal population distribution used to calibrate the PROMIS instrument? (3) Do all orthopaedic patients with the lowest possible score (floor effect) on the PROMIS Depression questionnaire answer questions more quickly than those who do not?Methods Between February 12, 2015 and July 19, 2018, a total of 513,042 patients with orthopaedic conditions at a single urban, tertiary academic medical center were asked to complete the PROMIS PF, PI, and Depression domains. The PROMIS PF, PI, and Depression questionnaires were administered at 433,939 patient encounters (85%), and 325,251 of 433,939 (75%) completed all three questionnaires and were included in our final sample. The remaining encounters were excluded from all analyses because of incomplete PROMIS data. Using this large sample size, we determined the distributions of the PROMIS PF, PI, and Depression domains for all patients with orthopaedic conditions by visual inspection. We calculated the percentage of patients with the lowest possible score on the PROMIS Depression domain (“floor group”) for all patients with orthopaedic conditions, as well for patients presenting to orthopaedic subspecialists (foot and ankle, spine, upper extremity, multiple subspecialties, or other specialists). We compared patient and PROMIS characteristics between patients in the floor group and all others (“standard group”) using a bivariate analysis, including the total time it took to complete the questionnaires and average time it took to answer each question.
Results Of the three PROMIS domains analyzed, only the PROMIS PF demonstrated a normal distribution on visual inspection. PROMIS PI scores had a measurable ceiling effect (more pain symptoms) (15,520 of 325,251 patient encounters; 5%), while PROMIS Depression scores demonstrated a clear floor effect (65,226 of 325,251; 20%). When analyzed by subspecialty, there was a clear floor effect for the PROMIS Depression in the specialties of foot and ankle (6031 of 29,273 patient encounters; 21%), spine (7611 of 58,266; 13%), upper extremity (9851 of 42,864; 23%), multiple subspecialties (276 of 1662; 17%), and other (41, 454 of 193,185; 22%). Generally, those in the floor group spent less time per question on the PROMIS Depression questionnaire than did those in the standard group (5.3 seconds ± 2.6 seconds versus 8.1 seconds ± 4.6 seconds; mean difference, 2.8 seconds; p < 0.001).
Conclusions The substantial floor effect of the PROMIS Depression in the setting of hasty completion raises the question of whether such results truly indicate that these patients have minimal depression or whether they simply do not report their true mental health status in an orthopaedic setting. When such patients are seen in clinic, surgeons may benefit from using the PROMIS Depression as an educational opportunity to explain the importance of mental health in orthopaedic care and ensure the questionnaire is completed accurately. This study builds on previous work by suggesting these findings apply to other general and subspecialty orthopaedic patient populations at academic medical centers. Future work may seek to determine the best way of ensuring that the PROMIS Depression questionnaire is completed accurately in orthopaedic clinics.
Level of Evidence Level II, diagnostic study.

CORR Insights®: Determining the Generalizability of the PROMIS Depression Domain’s Floor Effect and Completion Time in Patients Undergoing Orthopaedic Surgery

01-10-2019 – Hamilton, David F.

Journal Article

No abstract available

Does Knee Flexion Influence the Relationship between the Femoral Tunnel and the Lateral Anatomic Structures During ACL Reconstruction?

01-10-2019 – Chung, Kwangho; Kim, Sung-Jae; Choi, Chong Hyuk; Kim, Sung-Hwan; Choi, Yunjong; Jung, Min

Journal Article

Background In ACL reconstruction, the relationship of the femoral tunnel outlet to the anatomy of the lateral knee is clinically important, but whether that relationship is influenced by knee flexion using a transportal technique is unclear.
Questions/purposes The purposes of this study were to (1) to describe the relationship between the outlet of the femoral tunnel and the lateral anatomic structures of the femur, including the lateral epicondyle, lateral collateral ligament, popliteus tendon, and lateral head of the gastrocnemius, as a function of knee flexion angle when the tunnel was created; and (2) to determine the knee flexion range of angles that best limits the risk of damage to these structures as the femoral tunnel is created during anatomic single-bundle ACL reconstruction using the transportal technique.
Methods Between January 2017 and June 2018, 113 patients underwent ACL reconstruction, of which 62 (55%) who had a primary single-bundle ACL reconstruction with transportal technique using autogenous quadruple hamstring graft were included. Patients who were treated with grafts other than autogenous quadruple hamstring tendon, and had concomitant ligamentous injury, revisional ACL reconstruction, previous operative history of the affected knee, osseous deformity and osteoarthritis were excluded. Included patients were divided into three groups according to their knee flexion angles as the femoral tunnel was created. The femoral tunnel was created with rigid straight reamer with the knee flexed as much as possible in figure-of-four position and the flexion angle was measured with a sterile 12-inch goniometer intraoperatively for all patients. Fourteen patients (23%) had the femoral tunnel created with the knee in 0.75). The distances were compared among the groups, and a correlation analysis of the measured distances regarding the knee flexion angle during creation of the femoral tunnel was performed. The safe distance was set as 12 mm between the centers of the femoral tunnel’s outlet and the lateral structures considering the footprint of the lateral structures, diameter of the femoral tunnel, and femoral tunnel widening. Any anatomic structures that were closer to the femoral tunnel than the safe distance were noted, and the cutoff point of knee flexion for injury to the lateral anatomic structures was determined with a receiver operating characteristic curve.
Results As knee flexion angle increased, the distance from the femoral tunnel to the lateral head of the gastrocnemius increased (r = 0.657, p < 0.001), and the distance to the lateral epicondyle decreased (r = -0.627, p < 0.001), as did the distance of the tunnel to the lateral collateral ligament (r = -0.443, p < 0.001) and the popliteus tendon (r = -0.653, p < 0.001). The cutoff point of the knee flexion angle associated with structural injury was 131° (sensitivity, 70%; specificity, 73%) for the lateral collateral ligament and 121° (sensitivity, 86%; specificity, 67%) for the lateral head of the gastrocnemius.
Conclusions As knee flexion increased, the femoral tunnel’s outlet tended to move more anteriorly and distally. Consequently, the safe distance to the lateral head of the gastrocnemius increased and the distances to the lateral epicondyle, lateral collateral ligament, and popliteus tendon decreased with increased knee flexion. To avoid possible damage to the lateral anatomic structures and obtain stable fixation in ACL reconstruction using the transportal technique, we recommend creating a femoral tunnel within 121° and 131° of knee flexion.
Level of Evidence Level III, therapeutic study.

CORR Insights®: Does Knee Flexion Influence the Relationship between the Femoral Tunnel and the Lateral Anatomic Structures During ACL Reconstruction?

01-10-2019 – Fu, Freddie H.

Journal Article

No abstract available

Tilt-adjusted Cup Anteversion in Patients with Severe Backward Pelvic Tilt is Associated with the Risk of Iliopsoas Impingement: A Three-dimensional Implantation Simulation

01-10-2019 – Ueno, Takuro; Kabata, Tamon; Kajino, Yoshitomo; Ohmori, Takaaki; Yoshitani, Junya; Ueoka, Ken; Tsuchiya, Hiroyuki

Journal Article

Background Anterior overhang of the acetabular component is associated with iliopsoas impingement, which may cause groin pain and functional limitations after THA. However, little is known about the relationship between component overhang and functional alignment of the acetabular component. CT-based image simulation may be illuminating in learning more about this because CT images are more effective than radiographs for evaluating the component’s overhang and position.
Questions/purposes Using CT simulations based on preoperative data of nondysplastic and dysplastic hips, we asked: (1) What are the differences in the amount of component overhang, defined as the mediolateral distance from the component’s edge to the native acetabular bony boundary on axial images (axial overhang), and as the AP distance on sagittal images (sagittal overhang) among pelvises with neutral and posterior tilt (in which the cephalad portion of the pelvis is more posterior than the caudad portion in the sagittal plane) in patients with dysplastic hips and those with nondysplastic hips? (2) Are increments in the amount of component overhang associated with a difference in the likelihood that the iliopsoas tendon will impinge against the edge of the acetabular component, after controlling for native acetabular abduction and anteversion and the presence of dysplasia?Methods A total of 128 hips (dysplastic group: 73 hips; nondysplastic group: 55 hips) were evaluated. We defined a dysplastic hip as one with a lateral center-edge angle of less than 20° on AP radiographs. Pelvic models with neutral (0°) and 10° and 20° of posterior tilt were created from CT data. In simulations, acetabular component models were implanted into the true acetabulum with a tilt-adjusted orientation angle that was defined as the component’s angle based on a reference for the functional pelvic plane (coronal plane of the body) in each pelvic model. Axial and sagittal component overhang were measured on CT images. Axial overhang of at least 12 mm and sagittal overhang of at least 4 mm were defined as thresholds increasing the likelihood of iliopsoas impingement according to previous studies. When determining the amount of overhang of the acetabular component, we controlled for abduction and anteversion of the native acetabulum and the presence of dysplasia by performing a multivariable logistic regression analysis.
Results In dysplastic hips, axial overhang increased by a mean ± SD of 5 ± 1 mm (Bonferroni adjusted p < 0.001; 95% CI, 4.7-5.1) from 0° to 10° of posterior tilt and by 5 ± 1 mm (p < 0.001; 95% CI, 4.9-5.3) from 10° to 20° of posterior tilt. Sagittal overhang increased by 1 ± 0 mm (p < 0.001; 95% CI, 1.0-1.0) from 0° to 10° of posterior tilt and by 1 ± 0 mm (p < 0.001; 95% CI, 1.0-1.0) from 10° to 20° of posterior tilt. In nondysplastic hips, axial overhang increased by a mean of 5 ± 0 mm (p < 0.001; 95% CI, 4.7-5.0) from 0° to 10° of posterior tilt and by 5 ± 1 mm (p < 0.001; 95% CI, 4.6-5.0) from 10° to 20° of posterior tilt. Sagittal overhang increased by 1 ± 0 mm (p < 0.001; 95% CI, 1.0-1.1) from 0° to 10° of posterior tilt and by 1 ± 0 mm (p < 0.001; 95% CI, 1.0-1.1) from 10° to 20° of posterior tilt. After controlling for the presence of dysplasia, we found that native acetabular abduction and anteversion and posterior pelvic tilt, presence of dysplasia (p = 0.030; adjusted odds ratio OR, 2.2; 95% CI, 1.1-4.6), native acetabular anteversion (p < 0.001; adjusted OR, 1.4; 95% CI, 1.3-1.5), and 10° and 20° of backward tilt compared with 0° of tilt (10° of posterior tilt: p < 0.001; adjusted OR, 15; 95% CI, 5.5-41; 20° of posterior tilt: p < 0.001; adjusted OR, 333; 95% CI, 96-1157) were independently associated with axial overhang of at least 12 mm; the model showed high goodness of fit (Nagelkerke’s r2 = 0.68). In contrast, native acetabular anteversion (p < 0.001; adjusted OR, 1.2; 95% CI, 1.1-1.2) and 20° of backward tilt compared with 0° of tilt (p = 0.015; adjusted OR, 2.2; 95% CI, 1.2-4.0) were independently associated with sagittal overhang of at least 4 mm; the model had low goodness of fit (Nagelkerke’s r2 = 0.20).
Conclusions Acetabular component overhang is more severe when the pelvis tilts posteriorly. Moreover, posterior pelvic tilt, the presence of dysplasia, and higher native acetabular anteversion were independently associated with an increased risk of component overhang. When 20° of posterior tilt was adjusted, the risk of severe overhang was especially increased.
Clinical Relevance Based on these results, surgeons can attempt to prevent severe overhang in patients with posterior pelvic tilt by increasing component anteversion and abduction; when component anteversion is increased by 8° and abduction is increased by 2° from the target angle of 15° of anteversion and 40° of abduction in patients with posterior tilt of 20°, the risk of severe overhang is reduced to by approximately one-twentieth. However, it is still unclear how much the degree of component anteversion should be increased when surgeons attempt to prevent anterior prosthetic dislocation at the same time. Future studies such as prospective clinical trials evaluating both prosthetic dislocation and iliopsoas impingement in patients with posterior tilt might clarify this issue.

CORR Insights®: Tilt-adjusted Cup Anteversion in Patients with Severe Backward Pelvic Tilt is Associated with the Risk of Iliopsoas Impingement: A Three-dimensional Implantation Simulation

01-10-2019 – Ilchmann, Thomas

Journal Article

No abstract available

What are the Factors Associated with Re-revision After One-stage Revision for Periprosthetic Joint Infection of the Hip? A Case-control Study

01-10-2019 – Abdelaziz, Hussein; Grüber, Hendrik; Gehrke, Thorsten; Salber, Jochen; Citak, Mustafa

Journal Article

Background Despite increased interest in one-stage revision arthroplasty for periprosthetic joint infection (PJI) of the hip, the reported infection-free proportions after the one-stage approach are still comparable to that of two-stage revision. However, we still lack studies that analyze factors associated with any re-revision after one-stage revision arthroplasty for PJI.
Questions/purposes After one-stage revision arthroplasty for PJI of the hip, what factors were associated with an increased risk of re-revision, and what factors were associated with an increased risk of reinfection?Methods We performed a single-center retrospective case-control analysis. Patients who underwent one-stage revision arthroplasty for PJI of the hip in our hospital between 2009 and 2017, and who were subsequently re-revised due to any reason, including reinfection, were identified from our electronic medical records. A total of 121 patients who underwent repeat revision for any reason after one-stage exchange for PJI of the hip were identified. The re-revision procedures were performed after a mean of 407 days. The primary reasons for re-revision were repeated hip dislocation in 53 of 121 patients (44%), reinfection including both new and persistent infections in 40 of 121 patients (33%), and aseptic loosening in 16 patients (13%). Forty-three patients underwent another revision procedure after the re-revision procedure (43 of 121; 36%). More than 40 potential patient-, joint- and surgery-related risk factors were investigated and compared with a 1:1 matched control participants by age, sex and year of the one-stage revision. Similar to the re-revision patients, controls were treated for PJI with one-stage revision arthroplasty; however, they did not undergo subsequent revision for any reason by the latest followup examination. The mean followup of the control group was 66 months (range, 17-119 months). The mean length of hospital stay was 26 days in the re-revised group (SD, 11.6 days) compared with 22 days for the controls (SD, 6.6 days). All analyses were performed to identify factors associated with general re-revision and reinfection.
Results The independent factors associated with repeat revision for any reason were persistent wound drainage for at least 1 week (odds ratio OR, 7.4; 95% CI, 2.6–20.6; p < 0.001), isolation of enterococci (OR, 4.8; 95% CI, 1.4–15.7; p = 0.010), and prior surgery due to infection before the one-stage hip revision (OR, 3.6; 95% CI, 2.0–6.4; p < 0.001). The factors associated with reinfection including both new and persistent infections were prolonged wound drainage (OR, 6.9; 95% CI, 2.2–21.5; p = 0.001) and prior surgery due to infection (OR, 4.3; 95% CI, 1.9–9.5; p < 0.001).
Conclusions Prolonged wound drainage after the one-stage revision arthroplasty for PJI of the hip must be treated rigorously. Patients with a history of a prior surgical procedure due to hip infection should be informed about the risk of further re-revision when deciding for the one-stage exchange. In case of enterococcal isolation, surgeons may consider another treatment approach rather than the one-stage exchange. Furthermore, we recommend the use of dual mobility cups when performing the one-stage revision hip arthroplasty to reduce the risk of dislocation.
Level of Evidence Level III, therapeutic study.

CORR Insights®: What are the Factors Associated With Re-revision After One-stage Revision for Periprosthetic Joint Infection of the Hip? A Case-control Study

01-10-2019 – Bedair, Hany

Journal Article

No abstract available

Polytrauma and High-energy Injury Mechanisms are Associated with Worse Patient-reported Outcomes After Distal Radius Fractures

01-10-2019 – van der Vliet, Q. M. J.; Sweet, A. A. R.; Bhashyam, A. R.; Ferree, S.; van Heijl, M.; Houwert, R. M.; Leenen, L. P. H.; Hietbrink, F.

Journal Article

Background Patient-reported outcomes (PROs) are increasingly relevant when evaluating the treatment of orthopaedic injuries. Little is known about how PROs may vary in the setting of polytrauma or secondary to high-energy injury mechanisms, even for common injuries such as distal radius fractures.
Questions/purposes (1) Are polytrauma and high-energy injury mechanisms associated with poorer long-term PROs (Euro
Qol Five Dimension Three Levels EQ-5D-3L and Quick
DASH scores) after distal radius fractures? (2) What are the median EQ-5D-3L, EQ-VAS Euro
Qol VAS, and Quick
DASH scores for distal radius fractures in patients with polytrauma, high-energy monotrauma and low-energy monotrauma
Methods This was a retrospective study with followup by questionnaire. Patients treated both surgically and conservatively for distal radius fractures at a single Level 1 trauma center between 2008 and 2015 were approached to complete questionnaires on health-related quality of life (HRQoL) (the EQ-5D-3L and the EQ-VAS) and wrist function (the Quick
DASH). Patients were grouped according to those with polytrauma (Injury Severity Score ISS ≥ 16), high-energy trauma (ISS < 16), and low-energy trauma based on the ISS score and injury mechanism. Initially, 409 patients were identified, of whom 345 met the inclusion criteria for followup. Two hundred sixty-five patients responded (response rate, 77% for all patients; 75% for polytrauma patients; 76% for high-energy monotrauma; 78% for low-energy monotrauma (p = 0.799 for difference between the groups). There were no major differences in baseline characteristics between respondents and nonrespondents. The association between polytrauma and high-energy injury mechanisms and PROs was assessed using forward stepwise regression modeling after performing simple bivariate linear regression analyses to identify associations between individual factors and PROs. Median outcome scores were calculated and presented.
Results Polytrauma (intraarticular: β -0.11; 95% confidence interval CI, -0.21 to -0.02; p = 0.015) was associated with lower HRQoL and poorer wrist function (extraarticular: β 11.9; 95% CI, 0.4–23.4; p = 0.043; intraarticular: β 8.2; 95% CI, 2.1–14.3; p = 0.009). High-energy was associated with worse Quick
DASH scores as well (extraarticular: β 9.5; 95% CI, 0.8–18.3; p = 0.033; intraarticular: β 11.8; 95% CI, 5.7–17.8; p < 0.001). For polytrauma, high-energy trauma, and low-energy trauma, the respective median EQ-5D-3L outcome scores were 0.84 (range, -0.33 to 1.00), 0.85 (range, 0.17–1.00), and 1.00 (range, 0.174–1.00). The VAS scores were 79 (range, 30–100), 80 (range, 50–100), and 80 (range, 40–100), and the Quick
DASH scores were 7 (range, 0– 82), 11 (range, 0–73), and 5 (range, 0–66), respectively.
Conclusions High-energy injury mechanisms and worse HRQoL scores were independently associated with slightly inferior wrist function after wrist fractures. Along with relatively well-known demographic and injury characteristics (gender and articular involvement), factors related to injury context (polytrauma, high-energy trauma) may account for differences in patient-reported wrist function after distal radius fractures. This information may be used to counsel patients who suffer a wrist fracture from polytrauma or high-energy trauma and to put their outcomes in context. Future research should prospectively explore whether our findings can be used to help providers to set better expectations on expected recovery.
Level of Evidence Level III, therapeutic study.

CORR Insights®: Polytrauma and High-energy Injury Mechanisms are Associated with Worse Patient-reported Outcomes Scores After Distal Radius Fractures

01-10-2019 – Lubahn, John D.

Journal Article

No abstract available

What Is the Effect of Vitamin C on Finger Stiffness After Distal Radius Fracture? A Double-blind, Placebo-controlled Randomized Trial

01-10-2019 – Özkan, Sezai; Teunis, Teun; Ring, David C.; Chen, Neal C.

Background It is proposed that vitamin C administration can reduce disproportionate pain and stiffness after distal radius fracture; however, randomized trials that tested this hypothesis have had inconsistent results.
Questions/purposes (1) Is administering vitamin C after distal radius fracture associated with better ROM, patient-reported upper extremity function, and pain scores? (2) What factors are associated with post-fracture finger stiffness and worse upper extremity function?Methods This is a double-blind, randomized, placebo-controlled, noncrossover study. Between August 2014 and July 2017, we approached 204 consecutive patients, of which 195 were eligible, and 134 chose to participate. Participants were randomized to receive once-daily 500 mg vitamin C (67 participants) or placebo (67 participants) within 2 weeks after distal radius fracture. All patients received usual care at the discretion of their surgeon. The mean age of participants was 49 ± 17 years, 99 patients (74%) were women, and 83 (62%) were treated nonoperatively. The primary outcome was the distance between the fingertip and distal palmar crease 6 weeks after fracture. This measure is easy to obtain and previously has been shown to correlate with aggregate ROM of all finger joints. The secondary outcomes were total active finger motion, total active thumb motion, upper extremity-specific limitations, and pain intensity.
An a priori power analysis suggested 126 patients would provide 80% power to detect a difference of 2 cm (SD 4.0) fingertip distance to palmar crease with α set at 0.05 using a two-tailed Students t-test. Accounting for 5% lost to followup, we included 134 patients.
All analyses were intention-to-treat. Ten participants of the intervention group and five of the placebo group were lost to followup. Their missing data were addressed by multiple imputation, after which we performed linear regression analysis for our outcome variables.
Results Administration of vitamin C was not associated with ROM, function, or pain scores at 6 weeks (distance to palmar crease: β -0.23; 95% CI -1.7 to 1.2; p = 0.754; finger ROM: β 4.9; 95% CI, -40 to 50; p = 0.829; thumb ROM: β 0.98; 95% CI, -18 to 20; p = 0.918, Patient-Reported Outcomes Measurement Information System PROMIS score: β 0.32; 95% CI, -2.6 to 3.2; p = 0.828; pain score: β -0.62; 95% CI, -0.62 to 0.89; p = 0.729) nor at 6 months (PROMIS score: β -0.21; 95% CI, -3.7 to 3.3; p = 0.904; pain score: β 0.31; 95% CI, -0.74 to 1.4; p = 0.559). At 6 weeks, we found that more finger stiffness was mildly associated with greater age (β -1.5; 95% CI, -2.8 to -0.083; p = 0.038). Thumb stiffness was mildly associated with greater age (β -0.72; 95% CI, -1.3 to -0.18; p = 0.009) and strongly associated with operative treatment (β -32; 95% CI, -50 to -13; p = 0.001). Greater pain interference was modestly associated with greater functional limitations at 6 weeks (β -0.32; 95% CI, -0.52 to -0.12; p = 0.002) and 6 months (β -0.36; 95% CI, -0.60 to -0.11; p = 0.004).
Conclusions Vitamin C does not seem to facilitate recovery after distal radius fracture, but amelioration of maladaptation to nociception (pain interference) merits greater attention.
Level of Evidence Level I, therapeutic study.

Elevated Controlling Nutritional Status (CONUT) Score is Associated with Poor Long-term Survival in Patients with Low-grade Soft-tissue Sarcomas Treated with Surgical Resection

01-10-2019 – Liang, Yao; Hou, Tao; Que, Yi; Zhao, Baiwei; Xiao, Wei; Zhang, Xing; Zhou, Zhiwei

Journal Article

Background Several studies have examined the Controlling Nutritional Status (CONUT) score, which is a screening tool for nutritional status and an effective biomarker for patient survival after cancer treatment. However, its role in soft-tissue sarcoma (STS) remains unknown. Because of the lack of predictive markers for survival in patients with STS, we aimed to determine the CONUT score’s association with survival.
Questions/purposes (1) Is there a relationship between the CONUT score and clinicopathologic characteristics such as tumor size, tumor location, pathological grade, and advanced stage based on the American Joint Committee on Cancer (AJCC) guidelines? (2) Is the CONUT score associated with disease-free survival (DFS) and overall survival (OS) in patients treated surgically for STS, even when compared with other systemic inflammatory response markers?Methods Between 1999 and 2016, 769 patients underwent R0 resection for STS at our institution. Adequate medical records and available followup data were required for inclusion in this study. Exclusion criteria were synchronous inflammatory diseases, unplanned excision, and neoadjuvant therapy. There were 658 patients (86%) who fulfilled all criteria. The minimum followup time was 24 months (median, 103 months; range, 61-147 months). The median age of the patients was 43 years (range, 5-85 years), and 265 patients (40%) were women. All patients had Stage I to IV tumors according to the 8th edition of the AJCC staging system. The grade classification was determined to be G1 in 130 patients (20%), G2 in 304 (46%), and G3 in 201 (31%). The CONUT score was calculated based on the serum albumin concentration, total peripheral lymphocyte count, and total cholesterol concentration. The score ranged from 0 to 12, with higher scores indicating worse nutritional status. The patients were classified into two groups according to a receiver operating characteristic curve analysis: the high (≥ 2) and low (0 or 1) CONUT score groups. There were 435 patients in the low CONUT score group and 223 in the high CONUT score group. We tested for an association between the CONUT scores and gender, age, tumor diameter, tumor depth, tumor grade, and AJCC stage using the chi-square and Fisher’s exact methods. We also compared the strength of the association between postoperative survival and the CONUT scores, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) using multivariate Cox proportional hazard model analyses.
Results High CONUT scores were associated with large tumor size (odds ratio OR, 1.47; 95% CI, 1.06-2.04; p = 0.020), deep tumor location (OR, 1.66; 95% CI, 1.17-2.36; p = 0.004), high tumor grade (OR, 2.54; 95% CI, 1.56-4.14; p = 0.001), and advanced AJCC stage (OR, 1.86; 95% CI, 1.14-3.02; p < 0.001). The low CONUT score group exhibited a higher 5-year OS rate and longer OS than the high CONUT score group (82% versus 65%; odds ratio, 2.45; 95% CI, 1.27-4.72; p < 0.001; 81 versus 64 months, Z = -2.56; p < 0.001). A multivariate analysis indicated that an elevated CONUT score was an independent predictor of OS (hazard ratio HR, 1.86; 95% CI, 1.47-4.14; p < 0.001) and DFS (HR, 1.63; 95% CI, 1.26-2.11; p < 0.001), but the NLR and PLR were not. In an individual subgroup analysis, the CONUT scores were associated with OS and DFS in the tumor diameter (< 5 or ≥ 5 cm) subgroup, tumor depth (superficial or deep) subgroup, tumor grade (G1 and G2) subgroup, and AJCC stage (I/II or III/IV) subgroup, but not in the G3 subgroup (p = 0.051 and p = 0.065).
Conclusion High CONUT scores were independently associated with aggressive tumor behavior and unfavorable survival for patients with low-grade, but not high-grade, resected STS. If these findings can be substantiated in larger studies, the CONUT score might be useful for predicting survival and help to develop new treatment strategies for nutrition interventions.
Level of Evidence Level III, therapeutic study.

Does the SORG Algorithm Predict 5-year Survival in Patients with Chondrosarcoma? An External Validation

01-10-2019 – Bongers, Michiel E. R.; Thio, Quirina C. B. S.; Karhade, Aditya V.; Stor, Merel L.; Raskin, Kevin A.; Lozano Calderon, Santiago A.; DeLaney, Thomas F.; Ferrone, Marco L.; Schwab, Joseph H.

Journal Article

Background We developed a machine learning algorithm to predict the survival of patients with chondrosarcoma. The algorithm demonstrated excellent discrimination and calibration on internal validation in a derivation cohort based on data from the Surveillance, Epidemiology, and End Results (SEER) registry. However, the algorithm has not been validated in an independent external dataset.
Questions/purposes Does the Skeletal Oncology Research Group (SORG) algorithm accurately predict 5-year survival in an independent patient population surgically treated for chondrosarcoma?Methods The SORG algorithm was developed using the SEER registry, which contains demographic data, tumor characteristics, treatment, and outcome values; and includes approximately 30% of the cancer patients in the United States. The SEER registry was ideal for creating the derivation cohort, and consequently the SORG algorithm, because of the high number of eligible patients and the availability of most (explanatory) variables of interest. Between 1992 to 2013, 326 patients were treated surgically for extracranial chondrosarcoma of the bone at two tertiary care referral centers. Of those, 179 were accounted for at a minimum of 5 years after diagnosis in a clinical note at one of the two institutions, unless they died earlier, and were included in the validation cohort. In all, 147 (45%) did not meet the minimum 5 years of followup at the institution and were not included in the validation of the SORG algorithm. The outcome (survival at 5 years) was checked for all 326 patients in the Social Security death index and were included in the supplemental validation cohort, to also ascertain validity for patients with less than 5 years of institutional followup. Variables used in the SORG algorithm to predict 5-year survival including sex, age, histologic subtype, tumor grade, tumor size, tumor extension, and tumor location were collected manually from medical records. The tumor characteristics were collected from the postoperative musculoskeletal pathology report. Predicted probabilities of 5-year survival were calculated for each patient in the validation cohort using the SORG algorithm, followed by an assessment of performance using the same metrics as used for internal validation, namely: discrimination, calibration, and overall performance. Discrimination was calculated using the concordance statistic (or the area under the Receiver Operating Characteristic (ROC) curve) to determine how well the algorithm discriminates between the outcome, which ranges from 0.5 (no better than a coin-toss) to 1.0 (perfect discrimination). Calibration was assessed using the calibration slope and intercept from a calibration plot to measure the agreement between predicted and observed outcomes. A perfect calibration plot should show a 45° upwards line. Overall performance was determined using the Brier score, ranging from 0 (excellent prediction) to 1 (worst prediction). The Brier score was compared with the null-model Brier score, which showed the performance of a model that ignored all the covariates. A Brier score lower than the null model Brier score indicated greater performance of the algorithm. For the external validation an F1-score was added to measure the overall accuracy of the algorithm, which ranges between 0 (total failure of an algorithm) and 1 (perfect algorithm).
The 5-year survival was lower in the validation cohort than it was in the derivation cohort from SEER (61.5% 110 of 179 versus 76% 1131 of 1544 ; p < 0.001). This difference was driven by higher proportion of dedifferentiated chondrosarcoma in the institutional population than in the derivation cohort (27% 49 of 179 versus 9% 131 of 1544; p < 0.001). Patients in the validation cohort also had larger tumor sizes, higher grades, and nonextremity tumor locations than did those in the derivation cohort. These differences between the study groups emphasize that the external validation is performed not only in a different patient cohort, but also in terms of disease characteristics. Five-year survival was not different for both patient groups between subpopulations of patients with conventional chondrosarcomas and those with dedifferentiated chondrosarcomas.
Results The concordance statistic for the validation cohort was 0.87 (95% CI, 0.80–0.91). Evaluation of the algorithm’s calibration in the institutional population resulted in a calibration slope of 0.97 (95% CI, 0.68–1.3) and calibration intercept of -0.58 (95% CI, -0.20 to -0.97). Finally, on overall performance, the algorithm had a Brier score of 0.152 compared with a null-model Brier score of 0.237 for a high level of overall performance. The F1-score was 0.836. For the supplementary validation in the total of 326 patients, the SORG algorithm had a validation of 0.89 (95% CI, 0.85–0.93). The calibration slope was 1.13 (95% CI, 0.87–1.39) and the calibration intercept was -0.26 (95% CI, -0.57 to 0.06). The Brier score was 0.11, with a null-model Brier score of 0.19. The F1-score was 0.901.
Conclusions On external validation, the SORG algorithm retained good discriminative ability and overall performance but overestimated 5-year survival in patients surgically treated for chondrosarcoma. This internet-based tool can help guide patient counseling and shared decision making.
Level of Evidence Level III, prognostic study.

CORR Insights®: Does the SORG Algorithm Predict 5-year Survival in Patients with Chondrosarcoma? An External Validation

01-10-2019 – Wai, Eugene K.

Journal Article

No abstract available

The Dubousset Functional Test is a Novel Assessment of Physical Function and Balance

01-10-2019 – Diebo, Bassel G.; Challier, Vincent; Shah, Neil V.; Kim, David; Murray, Daniel P.; Kelly, John J.; Lafage, Renaud; Paulino, Carl B.; Passias, Peter G.; Schwab, Frank J.; Lafage, Virginie

Journal Article

Background Currently, the functional status of patients undergoing spine surgery is assessed with quality-of-life questionnaires, and a more objective and quantifiable assessment method is lacking. Dr. Jean Dubousset conceptually proposed a four-component functional test, but to our knowledge, reference values derived from asymptomatic individuals have not yet been reported, and these are needed to assess the test’s clinical utility in patients with spinal deformities.
Questions/purposes (1) What are the reference values for the Dubousset Functional Test (DFT) in asymptomatic people? (2) Is there a correlation between demographic variables such as age and BMI and performance of the DFT among asymptomatic people?Methods This single-institution prospective study was performed from January 1, 2018 to May 31, 2018. Asymptomatic volunteers were recruited from our college of medicine and hospital staff to participate in the DFT. Included participants did not report any musculoskeletal problems or trauma within 5 years. Additionally, they did not report any history of lower limb fracture, THA, TKA, or patellofemoral arthroplasty. Patients were also excluded if they reported any active medical comorbidities. Demographic data collected included age, sex, BMI, and self-reported race. Sixty-five asymptomatic volunteers were included in this study. Their mean age was 42 ± 15 years; 27 of the 65 participants (42%) were women. Their mean BMI was 26 ± 5 kg/m2. The racial distribution of the participants was 34% white (22 of 65 participants), 25% black (16 of 65 participants), 15% Asian (10 of 65 participants), 9% subcontinental Indian (six of 65 participants), 6% Latino (four of 65 participants), and 10% other (seven of 65 participants). In a controlled setting, participants completed the DFT after verbal instruction and demonstration of each test, and all participants were video recorded. The four test components included the Up and Walking Test (unassisted sit-to-stand from a chair, walk forward/backward 5 meters no turn, then unassisted stand-to-sit), Steps Test (ascend three steps, turn, descend three steps), Down and Sitting Test (stand-to-ground, followed by ground-to-stand, with assistance as needed), and Dual-Tasking Test (walk 5 meters forwards and back while counting down from 50 by 2). Tests were timed, and data were collected from video recordings to ensure consistency. Reference values for the DFT were determined via a descriptive analysis, and we calculated the mean, SD, 95% CI, median, and range of time taken to complete each test component, with univariate comparisons between men and women for each component. Linear correlations between age and BMI and test components were studied, and the frequency of verbal and physical pausing and adverse events was noted.
Results The Up and Walking Test was completed in a mean of 15 seconds (95% CI, 14-16), the Steps Test was completed in 6.3 seconds (95% CI, 6.0-6.6), the Down and Sitting Test was completed in 6.0 seconds (95% CI, 5.4-6.6), and the Dual-Tasking Test was performed in 13 seconds (95% CI, 12-14). The length of time it took to complete the Down and Sitting (r = 0.529; p = 0.001), Up and Walking (r = 0.429; p = 0.001), and Steps (r = 0.356; p = 0.014) components increased with as the volunteer’s age increased. No correlation was found between age and the time taken to complete the Dual-Tasking Test (r = 0.134; p = 0.289). Similarly, the length of time it took to complete the Down and Sitting (r = 0.372; p = 0.005), Up and Walking (r = 0.289; p = 0.032), and Steps (r = 0.366; p = 0.013) components increased with increasing BMI; no correlation was found between the Dual-Tasking Test’s time and BMI (r = 0.078; p = 0.539).
Conclusions We found that the DFT could be completed by asymptomatic volunteers in approximately 1 minute, although it took longer for older patients and patients with higher BMI.
Clinical Relevance We believe, but did not show, that the DFT might be useful in assessing patients with spinal deformities. The normal values we calculated should be compared in future studies with those of patients before and after undergoing spine surgery to determine whether this test has practical clinical utility. The DFT provides objective metrics to assess function and balance that are easy to obtain, and the test requires no special equipment.

CORR Insights®: The Dubousset Functional Test is a Novel Assessment of Physical Function and Balance

01-10-2019 – Krengel, Walter F. III

Journal Article

No abstract available

What Range of Motion and Functional Results Can Be Expected After Open Arthrolysis with Hinged External Fixation For Severe Posttraumatic Elbow Stiffness?

01-10-2019 – Sun, Ziyang; Cui, Haomin; Ruan, Jihao; Li, Juehong; Wang, Wei; Fan, Cunyi

Journal Article

Background The elbow is more susceptible to loss of motion after trauma than any other joint. Open arthrolysis often is performed for posttraumatic elbow stiffness if the stiffness does not improve with nonsurgical treatment, but the midterm results of this procedure and factors that may limit recovery have not been widely studied.
Questions/purposes We reviewed patients who had undergone open arthrolysis with hinged external fixator for severe posttraumatic elbow stiffness (ROM ≤ 60°) with a minimum of 5 years followup to (1) analyze ROM gains; (2) assess functional improvement with the Mayo Elbow Performance Index (MEPI) and DASH, quality of life with the SF-36, pain with VAS, and ulnar nerve function with the Amadio rating scale and Dellon classification; and (3) identify complications and risk factors that might hinder mid-term elbow motion recovery after this procedure.
Methods Between March 2011 and December 2012, we generally offered patients with elbow stiffness an open arthrolysis procedure when function did not improve with 6 months of nonoperative therapy, and no contraindications such as immature heterotopic ossification or complete destruction of articular cartilage were present. During that time, 161 patients underwent open arthrolysis for posttraumatic elbow stiffness at our institution; 49 of them satisfied the study inclusion criteria (adults with elbow ROM ≤ 60° as a result of trauma) and exclusion criteria (stiffness caused by burns or central nervous system injuries, causative trauma associated with nonunion or malunion of the elbow, severe articular damage that would have necessitated joint arthroplasty, or prior elbow release). In general, a combined medial-lateral approach to the elbow was performed to address the soft tissue tethers and any blocks to elbow motion, and a hinged external fixator was applied for 6 weeks to maintain elbow stability and improve the efficacy of postoperative rehabilitation. These patients were evaluated retrospectively at a mean followup period of 69 months (range, 62–83 months), and demographics, disease characteristics, arthrolysis details, pre- and postoutcome measures as noted, and complications were recorded via an electronic database. Multivariate regression analysis was performed to identify factors associated with ROM recovery.
Results At final followup, total ROM increased from a preoperative mean of 27 ± 20° to a postoperative mean of 131 ± 11° (mean difference, 104°; 95% CI, 98°–111°; p 120° (n = 40). After controlling for potential confounding variables such as duration of stiffness and tobacco use, we found that tobacco use was the only independent risk factor examined (odds ratio, 9; 95% CI, 2–47; p = 0.009) associated with recovery of ROM.
Conclusions Satisfactory medium-term results were found for open arthrolysis with hinged external fixation with our protocol in patients who had severe posttraumatic elbow stiffness. Appropriate and sufficient releases of tethered soft tissues and correction of any blocks that affect elbow motion intraoperatively, a dedicated team approach, and an aggressive and systematic postoperative rehabilitation program are the core steps for this procedure. Additionally, the importance of preoperative discontinuation of tobacco use should be emphasized.
Level of Evidence Level IV, therapeutic study.

CORR Insights®: Union Rates and Reported Range of Motion Are Acceptable After Open Forearm Fractures in Military Combatants

01-10-2019 – McHale, COL(R) Kathleen A.

Journal Article

No abstract available

Is Elective Soft Tissue Hand Surgery Associated with Periprosthetic Joint Infection after Total Joint Arthroplasty?

01-10-2019 – Li, Kevin; Jiang, Sam Y.; Burn, Matthew B.; Kamal, Robin N.

Journal Article

Background Although current guidelines do not recommend the routine use of surgical antibiotic prophylaxis to reduce the risk of surgical site infection following clean, soft tissue hand surgery, antibiotics are nevertheless often used in patients with an existing joint prosthesis to prevent periprosthetic joint infection (PJI), despite little data to support this practice.
Questions/purposes (1) Is clean, soft tissue hand surgery after THA or TKA associated with PJI risk? (2) Does surgical antibiotic prophylaxis before hand surgery decrease PJI risk in patients with recent THA or TKA?Methods We assessed all patients who underwent THA or TKA between January 2007 and December 2015 by retrospective analysis of the IBM® Market
Scan® Databases, which provide a longitudinal view of all healthcare services used by a nationwide sample of millions of patients under commercial and supplemental Medicare insurance coverage—particularly advantageous given the relatively low frequency of hand surgery after THA/TKA and of subsequent PJI. The initial search yielded 940,861 patients, from which 509,896 were excluded for not meeting continuous enrollment criteria, having a diagnosis of PJI before the observation period, or having another arthroplasty procedure before or during the observation period; the final study cohort consisted of 430,965 patients of which 147,398 underwent THA and 283,567 underwent TKA. In the treated cohort, 8489 patients underwent carpal tunnel release, trigger finger release, ganglion or retinacular cyst excision, de Quervain’s release, or soft-tissue mass excision within 2 years of THA or TKA. The control cohort was comprised of 422,476 patients who underwent THA or TKA but did not have subsequent hand surgery. The primary outcome was diagnosis or surgical management of a PJI within 90 days of the index hand surgery for the treated cohort, or within a randomly assigned 90-day observation period for each patient in the control group. Propensity score matching was used to match treated and control cohorts by patient and treatment characteristics and previously-reported risk factors for PJI. Logistic regression before and after propensity score matching was used to assess the association of hand surgery with PJI risk and the association of surgical antibiotic prophylaxis before hand surgery with PJI risk in the treated cohort. Other possible PJI risk factors were also explored in multivariable logistic regression. Statistical significance was assessed at α = 0.01.
Results Hand surgery was not associated with PJI risk after propensity score matching of treated and control cohorts (OR, 1.39; 99% CI, 0.60–3.22; p = 0.310). Among patients who underwent hand surgery after arthroplasty, surgical antibiotic prophylaxis before hand surgery was not associated with decreased PJI risk (OR 0.42; 99% CI, 0.03–6.08; p = 0.400).
Conclusions Clean, soft-tissue hand surgery was not found to be associated with PJI risk in patients who had undergone primary THA or TKA within 2 years before their hand procedure. While the effect of PJIs can be devastating, we do not find increased risk of infection with hand surgery nor data supporting routine use of surgical antibiotic prophylaxis in this setting.
Level of Evidence Level III, therapeutic study.

CORR Insights®: Is Elective Soft Tissue Hand Surgery Associated with Periprosthetic Joint Infection after Total Joint Arthroplasty?

01-10-2019 – Delanois, Ronald Emilio

Journal Article

No abstract available

Patient Characteristics, Treatment, and Presenting PROMIS Scores Associated with Number of Office Visits for Traumatic Hand and Wrist Conditions

01-10-2019 – Bernstein, David N.; Crijns, Tom J.; Mahmood, Bilal; Ring, David; Hammert, Warren C.

Journal Article

Background Overuse of healthcare resources is burdensome on society. Prior research has demonstrated that many patients with traumatic musculoskeletal injuries continue to seek care long after appropriate healing is well established, suggesting an overuse of services. However, few studies have examined the factors—including patient-reported outcomes—associated with an increased number of clinic visits for traumatic hand and wrist conditions.
Questions/purposes (1) After accounting for surgical treatment, surgeon, and demographic factors, is a patient’s PROMIS Pain Interference score associated with the total number of office visits? (2) Is PROMIS Depression, combination of PROMIS Depression and Pain Interference, or Physical Function scores associated with the number of office visits?Methods Between June 2015 and May 2018, 1098 patients presenting for a new patient visit at a single, urban academic medical center for distal radius fracture, wrist or hand sprain, tendon rupture, traumatic finger amputation, or scaphoid fracture were identified. Of those, 823 (75%) patients completed all PROMIS domains and presented before the trailing period and thus were included in this retrospective study. We recorded a number of variables including: Total number of office visits, age, sex, race, marital status, diagnosis, provider, and operative or nonoperative treatment. Multivariable Poisson regression analysis was conducted to determine whether Patient-Reported Outcomes Measurement Information System Pain Interference (PROMIS PI), Physical Function (PROMIS PF), and Depression scores measured at the first visit were associated with the total number of office visits, after accounting for the other factors we measured.
Results Higher PROMIS PI scores were associated with greater number of clinic visits (0.0077; 95% CI, 0.0018–0.014; p = 0.010). Although PROMIS Depression scores were not associated with the number of office visits (0.0042; 95% CI, -0.0099 to 0.0094; p = 0.112), higher PROMIS PF scores were associated with fewer office visits when accounting for confounding variables (-0.0077; 95% CI, -0.0012 to -0.0029; p = 0.001). Additionally, across all individual PROMIS models, there was an association between the variables “operative treatment” (PI: 0.85; 95% CI, 0.72–0.98; p < 0.001; Depression: 0.87; 95% CI, 0.74–1.0; p < 0.001; PF: 0.85; 95% CI, 0.72–0.99; p < 0.001) and “traumatic finger amputation” (PI: 0.22; 95% CI, 0.016–0.42; p = 0.034; Depression: 0.2; 95% CI, 0.086–0.47; p = 0.005; PF: 0.21; 95% CI, 0.014–0.41; p = 0.036) with an increased total number of office visits. Provider team 5 (PI: -0.62; 95% CI, -0.98 to -0.27; p = 0.001; Depression: -0.61; 95% CI, -0.96 to -0.26; p = 0.001; PF: -0.60; 95% CI, -0.96 to -0.25; p = 0.001) was associated with fewer office visits. In both the PROMIS Depression and PROMIS PF regression models, increasing age (Depression: -0.0048; 95% CI, -0.0088 to -0.00081; p = 0.018; PF: -0.0045; 95% CI, -0.0085 to -0.0006; p = 0.024) was also associated with fewer total number of office visits.
Conclusions This study helps surgeons understand that patients who present at their initial office visit for traumatic hand and wrist conditions displaying worse pain coping strategies and decreased physical function will have more office visits. We recommend that surgeons engage in a comprehensive care approach that is empathetic, fosters effective pain coping strategies (and so might decrease PROMIS PI scores), and educates patients about expectations by providing educational materials and/or including other health professionals (such as, social work, physical therapy, mental health professional) as needed. This may decrease healthcare use in patients with traumatic hand and wrist conditions.
Level of Evidence Level IV, prognostic study.

CORR Insights®: Patient Characteristics, Treatment, and Presenting PROMIS Scores Associated with Number of Office Visits for Traumatic Hand and Wrist Conditions

01-10-2019 – Chen, Neal C.

Journal Article

No abstract available

What Are the Implications of Alternative Alpha Thresholds for Hypothesis Testing in Orthopaedics?

01-10-2019 – Landy, David C.; Utset-Ward, Thomas J.; Lee, Michael J.

Journal Article

Background Clinical research in orthopaedics typically reports the presence of an association after rejecting a null hypothesis of no association using an alpha threshold of 0.05 at which to evaluate a calculated p value. This arbitrary value is a factor that results in the current difficulties reproducing research findings. A proposal is gaining attention to lower the alpha threshold to 0.005. However, it is currently unknown how alpha thresholds are used in orthopaedics and the distribution of p values reported.
Questions/purposes We sought to describe the use of alpha thresholds in two orthopaedic journals by asking (1) How frequently are alpha threshold values reported? (2) How frequently are power calculations reported? (3) How frequently are p values between 0.005 and 0.05 reported for the main hypothesis? (4) Are p values less than 0.005 associated with study characteristics such as design and reporting power calculations?Methods The 100 most recent original clinical research articles from two leading orthopaedic journals at the time of this proposal were reviewed. For studies without a specified primary hypothesis, a main hypothesis was selected that was most consistent with the title and abstract. The p value for the main hypothesis and lowest p value for each study were recorded. Study characteristics including details of alpha thresholds, beta, and p values were recorded. Associations between study characteristics and p values were described. Of the 200 articles (100 from each journal), 23 were randomized controlled trials, 141 were cohort studies or case series (defined as a study in which authors had access to original data collected for the study purpose), 31 were database studies, and five were classified as other.
Results An alpha threshold was reported in 166 articles (83%) with all but two reporting a value 0.05. Forty-two articles (21%) reported performing a power calculation. The p value for the main hypothesis was less than 0.005 for 88 articles (44%), between 0.05 and 0.005 for 67 (34%), and greater than 0.05 for 29 (15%). The smallest p value was between 0.05 and 0.005 for 39 articles (20%), less than 0.005 for 143 (72%), and either not provided or greater than 0.05 for 18 (9%). Although 50% (65 of 130) cohort and database papers had a main hypothesis p value less than 0.005, only 26% (6 of 23) randomized controlled trials did. Only 36% (15 of 42) articles reporting a power calculation had a p value less than 0.005 compared with 51% (73 of 142) that did not report one.
Conclusions Although a lower alpha threshold may theoretically increase the reproducibility of research findings across orthopaedics, this would preferentially select findings from lower-quality studies or increase the burden on higher quality ones. A more-nuanced approach could be to consider alpha thresholds specific to study characteristics. For example, randomized controlled trials with a prespecified primary hypothesis may still be best evaluated at 0.05 while database studies with an abundance of statistical tests may be best evaluated at a threshold even below 0.005.
Clinical Relevance Surgeons and scientists in orthopaedics should understand that the default alpha threshold of 0.05 represents an arbitrary value that could be lowered to help reduce type-I errors; however, it must also be appreciated that such a change could increase type-II errors, increase resource utilization, and preferentially select findings from lower-quality studies.

CORR Insights®: What Are the Implications of Alternative Alpha Thresholds for Hypothesis Testing in Orthopaedics?

01-10-2019 – O’Connor, Daniel P.

Journal Article

No abstract available

What Are the Effects of Irreversible Electroporation on a Staphylococcus aureus Rabbit Model of Osteomyelitis?

01-10-2019 – Muñoz, Nina M.; Minhaj, Adeeb A.; Dupuis, Crystal J.; Ensor, Joe E.; Golardi, Natalia; Jaso, Jesse M.; Dixon, Katherine A.; Figueira, Tomas Appleton; Galloway-Peña, Jessica R.; Hill, Lori; Shelburne, Samuel A.; Tam, Alda L.

Journal Article

Background The treatment of osteomyelitis can be challenging because of poor antibiotic penetration into the infected bone and toxicities associated with prolonged antibiotic regimens to control infection. Irreversible electroporation (IRE), a percutaneous image-guided ablation technology in which the targeted delivery of high-voltage electrical pulses permanently damages the cell membrane, has been shown to effectively control bacterial growth in various settings. However, IRE for the management of bone infections has yet to be evaluated.
Questions/purposes We aimed to evaluate IRE for treating osteomyelitis by assessing (1) the efficacy of IRE to suppress the in vitro growth of a clinical isolate of S. aureus, alone or combined with cefazolin; and (2) the effects of IRE on the in vivo treatment of a rabbit model of osteomyelitis.
Methods S. aureus strain UAMS-1 expanded in vitro to the log phase was subjected to an electric field of 2700 V/cm, which was delivered in increasing numbers of pulses. Immediately after electroporation, bacteria were plated on agar plates with or without cefazolin. The number of colony-forming units (CFUs) was scored the following day. ANOVA tests were used to analyze in vitro data. In a rabbit osteomyelitis model, we inoculated the same bacterial strain into the radius of adult male New Zealand White rabbits. Three weeks after inoculation, all animals (n = 32) underwent irrigation and débridement, as well as wound culture of the infected forelimb. Then, they were randomly assigned to one of four treatment groups (n = eight per group): untreated control, cefazolin only, IRE only, or combined IRE + cefazolin. Serial radiography was performed to assess disease progression using a semiquantitative grading scale. Bone and soft-tissue specimens from the infected and contralateral forelimbs were collected at 4 weeks after treatment for bacterial isolation and histologic assessment using a semiquantitative scale.
Results The in vitro growth of S. aureus UAMS-1 was impaired by IRE in a pulse-dependent fashion; the number of CFUs/m
L was different among seven pulse levels, namely 0, 10, 30, 60, 90, 120, and 150 pulses. With the number of CFUs/m
L observed in untreated controls set as 100%, 10 pulses rendered a median of 50.2% (range 47.1% to 58.2%), 30 pulses rendered a median of 2.7% (range 2.5% to 2.8%), 60 pulses rendered a median of 0.014% (range 0.012% to 0.015%), 90 pulses rendered a median of 0.004% (range 0.002% to 0.004%), 120 pulses rendered a median of 0.001% (range 0.001% to 0.001%), and 150 pulses rendered a median of 0.001% (range 0.000% to 0.001%) (Kruskal-Wallis test: p = 0.003). There was an interaction between the effect of the number of pulses and the concentration of cefazolin (two-way ANOVA: F 8, 30 = 17.24; p < 0.001), indicating that combining IRE with cefazolin is more effective than either treatment alone at suppressing the growth of S. aureus UAMS-1. Likewise, the clinical response in the rabbit model (the percentage of animals without detectable residual bacteria in the bone and surrounding soft tissue after treatment) was better in the combination group than in the other groups: control, 12.5% (one of eight animals); IRE only, 12.5% (one of eight animals); cefazolin only, 25% (two of eight animals); and IRE + cefazolin, 75% (six of eight animals) (two-sided Fisher’s exact test: p = 0.030).
Conclusions IRE effectively suppressed the growth of S. aureus UAMS-1 and enhanced the antibacterial effect of cefazolin in in vitro studies. When translated to a rabbit osteomyelitis model, the addition of IRE to conventional parenteral antibiotic treatment produced the strongest response, which supports the in vitro findings.
Clinical Relevance Our results show that IRE may improve the results of standard parenteral antibiotic treatment, thus setting the stage for models with larger animals and perhaps trials in humans for validation.

CORR Insights®: What Are the Effects of Irreversible Electroporation on a: Staphylococcus aureus: Rabbit Model of Osteomyelitis?

01-10-2019 – Jennings, Jessica Amber

Journal Article

No abstract available

Classifications in Brief: The Dejour Classification of Trochlear Dysplasia

01-10-2019 – Kazley, Jillian M.; Banerjee, Samik

Journal Article

No abstract available

Erratum to: What is the Diagnostic Accuracy of MRI for Component Loosening in THA?

01-10-2019 – Burge, Alissa J.; Konin, Gabrielle P.; Berkowitz, Jennifer L.; Lin, Bin; Koff, Matthew F.; Potter, Hollis G.

No abstract available

Erratum to: In Brief: Gustilo-Anderson Classification

01-10-2019 – Kim, Paul H.; Leopold, Seth S.

No abstract available

Erratum to: Do Skills Acquired from Training with a Wire Navigation Simulator Transfer to a Mock Operating Room Environment?

01-10-2019 – Long, Steven; Thomas, Geb; Karam, Matthew; Anderson, Donald D.

Journal Article

No abstract available