Board-certified Orthopaedic Surgeons Research Articles

Safety and Early Results for Off-Label Use of Intranasal Calcitonin for Treatment of Nondisplaced Acromial and Scapular Spine Stress Fractures After Reverse Total Shoulder Arthroplasty.

Immobilization for acromial and scapular spine stress AU4fractures (AF/SSF) after reverse total shoulder arthroplasty (RSA) is associated with patient dissatisfaction. Our study reports the effects and safety of intranasal calcitonin alongside sling immobilization on pain and function in the treatment of AF/SSF after RSA. The treatment was regimented calcitonin (salmon) 200 unit/actuation nasal spray (1 spray/day) for 6 weeks with sling immobilization for 4 weeks. Each patient was monitored through blood work. Visual analog scale, American Shoulder and Elbow Surgeons score, and active range of motion were collected preoperatively, postoperatively, at presentation of AF/SSF, and after completion of calcitonin treatment. Two hundred eighty-two RSAs were performed by two board-certified orthopaedic surgeons, of which 18 patients sustained AF/SSF (6.4%). Ten patients met inclusion criteria (nine AFs and one SSF). After calcitonin treatment, patients demonstrated an average improvement of visual analog scale of 5.8 points, active range of motion of 46_, and American Shoulder and Elbow Surgeons score of 43.6 points at average 7.53 months after RSA. No medical complications were reported at 6-month follow-up after calcitonin treatment. The use of intranasal calcitonin was not associated withadverse events including no aberrations/signs of cancer at 6-month follow-up after administration. Calcitonin with sling immobilization markedly improved clinical and functional outcomes of patients with nondisplaced AF/SSF and may be considered by orthopaedic surgeons for symptom management.

A Novel Evaluation for Vertebral Artery Course Using 3D Magnetic Resonance Imaging with Computed Tomography -like Bone Contrast and Magnetic Resonance Angiography: A Proof of Concept Study

Vertebral artery (VA) injury poses a significant risk in cervical spine surgery, necessitating accurate preoperative assessment. This study aims to introduce and validate a novel approach that combines the Fast field echo that resembles a computed tomography using restricted echo spacing (FRACTURE) sequence with Time of Flight (TOF) Magnetic Resonance Angiography (MRA) for comprehensive evaluation of VA courses in the cervical spine. A total of eight healthy volunteers and two patients participated in this study. The FRACTURE sequence provided high-resolution bone images of the cervical spine, while TOF MRA offered non-invasive vascular imaging. Fusion images were created by merging FRACTURE and MRA modalities to simultaneously visualize cervical spine structures and VA courses. Board-certified orthopedic spine surgeons independently evaluated images to assess the visibility of anatomical characteristics of the VA course by Likert-scale. The FRACTURE-MRA fusion images effectively depicted the extraosseous course of the VA at the craniovertebral junction, the intraosseous course of the VA at the craniovertebral junction, the VA entrance level to the transverse foramen, and the side-to-side asymmetry of bilateral VAs. Additionally, clinical cases demonstrated the utility of the proposed technique in identifying anomalies and guiding surgical interventions. The integration of the FRACTURE sequence and TOF MRA presents a promising methodology for the precise evaluation of VA courses in the cervical spine. This approach improves preoperative planning for cervical spine surgery with detailed anatomy and is a valuable alternative to conventional methods without contrast agents.

Assessment of Surgical Training Modality Efficacy in Medical Students – A Comparison of Surgical Simulation, Video Demonstration, and Live Instruction

Objectives Surgical simulation is a growing form of education in medical training, but it remains unclear how simulation compares to traditional lecture or apprenticeship models of teaching when translating procedural knowledge to surgical performance. This study aimed to assess the effectiveness of translating procedural knowledge to surgical skill when trained by the surgical simulation app “Touch Surgery (TS),” recorded video lecture, or in-person teaching of the trigger finger release (TFR) surgery. The study also aimed to identify the learners’ preferred teaching modality. Methods Twenty-seven first- and second-year medical students were recruited to participate. They were randomly assigned to one of three cohorts (n=9) as designated by a different TFR surgery learning modality: surgical simulation through TS (cohort “SS”), video demonstration (cohort “VIDEO”), or live teaching by a board-certified orthopaedic hand surgeon (cohort “LIVE”). Each participant completed their modality three times. They then completed an assessment of the procedural steps before performing the TFR surgery on a cadaver. Outcome measures included procedural test scores and cadaveric performance, evaluated using a surgery-specific detailed checklist, a global rating scale (GRS) of soft surgical skills, and a pass/fail assessment. Participants graded their modality’s usefulness using a 5-point Likert scale. Results There was no statistically significant difference in TFR procedural assessment scores (P=0.123) or cadaveric surgical performance between groups when evaluated by the surgery-specific step checklist (P=0.549), GRS (P=0.567), and pass/fail assessment (P=0.874). Students in the LIVE cohort rated their modality as their first-choice training tool (P=0.009); however, those in the SS cohort rated their modality as easiest to use, follow, and understand (P=0.010). Conclusion All educational modalities should be considered in surgical training. This study demonstrates that students can perform cognitively and technically similar learning from virtual or live formats; however, they preferred live teaching. Level of Evidence III

Early Postoperative Stiffness After Arthroscopic Rotator Cuff Repair Correlates With Improved Tendon Healing

PurposeThis study assessed if early postoperative stiffness predicts long-term stiffness and its relationship with repair integrity in arthroscopic rotator cuff repair (ARCR) patients. MethodsSingle-center retrospective study. 427 patients undergoing primary ARCR by a board-certified orthopaedic surgeon over four years were considered. Patients with at least one year of follow-up were categorized into stiff and non-stiff groups based on their range of motion (ROM) at three months postoperatively. Stiffness was defined as passive forward flexion <120°, external rotation <30°, or internal rotation below L3. We evaluated clinical outcomes using demographics, ROM, Constant Shoulder (CS) score, University of California, Los Angeles (UCLA) score, and visual analog scale (VAS) for pain preoperatively and at 3, 6, and 12 months postoperatively. Stiffness, retear rates, and tendon integrity were assessed via MRI at 12 months. ResultsOf 155 patients meeting the inclusion criteria, 68 (43.9%) were stiff, and 87 (56.1%) were non-stiff. The stiff group had significantly lower preoperative CS and UCLA scores (P=.013/.014) and higher VAS score (P=.034). At 3 months, this group showed lower ROM and functional scores (P<.001), persisting at 6 and 12 months (except internal rotation) (P<.001). Their 12-month VAS score was higher (P=.024). Postoperative stiffness occurred in 10.3% of the stiff group and 2.3% of the non-stiff group (P=.035). The 12-month retear rate was 5.9% in the stiff group and 17.2% in the non-stiff group (P=.032). Minimal clinically important difference (MCID) analysis indicated ROM changes but limited functional score changes in the two groups. ConclusionThis study showed that early postoperative shoulder stiffness correlates with lower preoperative functional scores and higher pain levels. Shoulder stiffness at three months post-ARCR predicts 12-month shoulder stiffness but indicates better tendon integrity. While early stiffness is linked to lower functional scores and more pain, its long-term clinical impact seems limited.

Occupational injuries in orthopedic and trauma surgeons in Austria

BackgroundThe aim of this study was to investigate the frequency and type of injuries during the career of orthopedic and trauma surgeons in Austria. The hypothesis was that the percentage of occupational injuries among orthopedic and trauma surgeons aligns with the incidence reported in the United States, thus indicating the need for a workplace prevention program.MethodsA web-based survey was created to collect all necessary data and was sent to all orthopedic and trauma surgeons in Austria via e-mail. Relevant parameters included the surgeons’ age, work experience, severity of pain, type of injury, and current pain. Descriptive and explorative statistical analysis was performed.ResultsA web-based survey was sent to 1122 board-certified orthopedic surgeons and residents in Austria via e-mail. In total, the response rate was 135 (12%). Seventy-two surgeons (54%) had suffered from one or more occupational injuries during their career. We detected a significant raise of occupational injuries related to the work life duration in which operations were performed and the prevalence of injuries. Most injuries of surgeons were reported between 21 and 30 years of their professional life. According to the frequency at different locations, the distribution in descending order was 25% with injuries of the hand, 22% of finger(s), 12% of the foot, 10% of the spine, 2% of the neck, 3% of the head, and 2% of the abdomen. A causality of incapacity to work through injuries at the workplace was given as 4%. Four percent stated a sick leave of at least 3 weeks. In 7% of the facilities, there was no optimization of preventive measures following an occupational injury. We found no correlation of injuries and resident status.ConclusionOrthopedic surgeons in Austria show a high incidence of occupational injuries in line with the findings of colleagues from the United States. The impact on the health system consists of absenteeism in the workplace of highly specialized health service providers as well as the incapacity to work of a high quality, highly trained workforce of at least 4%. With more preventive measures and more attention and care in the rehabilitation phase after such injuries, a positive effect could be achieved. We believe that residents should be specifically trained on how to avoid such injuries.

Physeal Closure and Fracture Pattern in Adolescent Transitional Distal Radius Fractures.

To show a correlation between grade of physeal closure and fracture pattern in adolescent transitional distal radius fractures. A retrospective chart review was performed of 490 distal radius fractures, ages 14 to 18, at a single institution between 2007 and 2020. A board-certified orthopaedic hand surgeon reviewed all images. Thirty-six distal-radius fractures were considered adolescent transitional fractures. The review included Salter-Harris classification, fracture fragments, and grade of physeal closure. Distal radial physeal closure is 50 times more likely to be of a higher grade in the presence of Salter-Harris type IV fractures ( P <0.001). Closure of the physis is also 7.37 and 13.08 times more likely to be of higher grade in the absence of a dorsal metaphyseal fracture and in the presence of an ulnar corner fracture, respectively ( P =0.011 and 0.021). Adolescent transitional fractures of the distal radius occur when the growth plate has a partial closure. The closure pattern of the distal radial physis begins centrally, with subsequent ulnar and then radial closure. In this cohort, there is a correlation between grade of physeal closure and fracture pattern in adolescent transitional distal radius fractures. Level IV-diagnostic.

Improving alignment in total knee arthroplasty: a cadaveric assessment of a surgical navigation tool with computed tomography imaging

Purpose To investigate the accuracy of an imageless, optical surgical navigation tool to assist with femoral and tibial bone cuts performed during TKA. Patients and methods Six board-certified orthopedic surgeons participated in a laboratory cadaver investigation, performing femoral and tibial bone cuts with the assistance of a computer navigation tool. Femoral and tibial varus/valgus, tibial slope, femoral flexion, and both femoral and tibial rotation measurements from the device were compared with angular measurements calculated from computed tomography (CT) images of the knees. Results Measurements with the navigation tool were highly correlated with those obtained from CT scans in all three axes. For the distal femoral cut, the absolute mean difference in varus/valgus was 0.83° (SD 0.46°, r = 0.76), femoral flexion was 1.91° (SD 1.16°, r = 0.85), and femoral rotation was 1.29° (SD 1.01°, r = 0.88) relative to Whiteside’s line and 0.97° (SD 0.56°, r = 0.81) relative to the posterior condylar axis. For the tibia, the absolute mean difference in varus/valgus was 1.08° (SD 0.64°, r = 0.85), posterior slope was 2.78° (SD 1.40°, r = 0.60), and rotation relative to the anteroposterior axis (posterior cruciate ligament to the medial third of the tibial tuberosity) was 2.98° (SD 2.54°, r = 0.79). Conclusion Utilization of an imageless navigation tool may aid surgeons in accurately performing and monitoring femoral and tibial bone cuts, and implant rotation in TKA and thus, more accurately align TKA components.

Poster 172: Subpectoral open versus Arthroscopic Biceps Tenodesis with concomitant Arthroscopic Rotator Cuff Repair does not impact ability to achieve Minimal Clinically Important Difference with use of Patient Reported Outcome Measurement System

Objectives: Disagreement exists within the current literature as to whether performing an arthroscopic vs. open subpectoral bicep tenodesis with concomitant arthroscopic rotator cuff repair (ARCR) leads to significantly different outcomes. Therefore, the objective of this study is to use a matched cohort of patients who undergo arthroscopic versus subpectoral biceps repair with concomitant ARCR and assess if there is a significant difference in (Patient-Reported Outcomes Measurement Information System) PROMIS outcomes and the ability to achieve a minimal clinically important difference (MCID). Methods: Data from the electronic medical record, including operative reports, were retrospectively collected for patients who underwent ARCR performed by one of six fellowship-trained board-certified orthopedic surgeons at a single institution. Current Procedural Terminology (CPT) for open or arthroscopic biceps tenodesis with concomitant arthroscopic rotator cuff repair was used to identify patients who underwent this procedure concomitant with ARCR between 01/01/2016 to 12/31/2019.Preoperative PROMIS physical function (PF), pain interference (PI), and depression (Dep) scores were obtained at the closest date prior to arthroscopic rotator cuff repair, and postoperative scores were collected at every clinical visit thereafter. The final PROMIS score used for data analysis was determined by the patients’ PROMIS scores between 90 and 180 days. A delta PROMIS value was determined by taking the difference between the final PROMIS score and the preoperative score. Unadjusted bivariate analysis was performed to assess the differences in PROMIS outcomes between the two cohorts. The MCID was determined as one-half of the standard deviation of a given PROMIS value, which is consistent with the current orthopedic literature. Results: A total of 297 patients were identified underwent rotator cuff repair with concomitant biceps tenodesis. A total of 151 subjects underwent arthroscopic biceps tenodesis with concomitant ARCR, while 147 underwent open subpectoral bicep tenodesis. The average time to follow up was 132.2 days for the arthroscopic cohort and 136.3 days for the subpectoral open group.Bivariate analysis demonstrated no significant difference between the two cohorts for insurance, race, ethnicity, last PROMIS input day, mechanism of injury, ASA class, or Charleston Comorbidity Index (CCI). There was a significant difference for patients who required contaminant subscapularis repair (p &lt; 0.001) and revision surgery (p &lt; 0.001).Unadjusted t-test analysis showed that patients in the arthroscopic biceps tenodesis cohort had significantly higher postoperative PROMIS PF and lower PROMIS PI and Dep scores. (P = 0.001, P = 0.001, and P = 0.007, respectively) when compared to their preoperative PROMIS values. The subpectoral open biceps tenodesis cohort did not show a significant difference in the postoperative PROMIS Dep score when compared to its preoperative score (P = 0.18), but it did show a significant improvement for postoperative PROMIS PF and PI (P = 0.001 and P = 0.04, respectively). No significant difference was determined between the arthroscopic bicep and subpectoral bicep tenodesis cohorts for delta PROMIS PF, PI, and Dep (P = 0.50, P = 0.51, and P = 0.10, respectively). A chi-square analysis found no significant difference between the achievement of MCID for PROMIS PF, PI, and Dep (P = 0.64, P = 0.72, and P = 0.95, respectively). Finally, no significant difference was determined between the time it took to achieve a minimal clinically important difference for PROMIS PF, PI, or Dep for patients who underwent arthroscopic rotator cuff repair with concomitant arthroscopic biceps tenodesis when compared to subpectoral open biceps tenodesis. Conclusions: The objective of this study was to assess differences in PROMIS outcomes for patients who undergo ARCR with concomitant arthroscopic or open subpectoral bicep tenodesis. The main findings of our study highlighted that patients with arthroscopic biceps tenodesis showed significant improvement at six months for PROMIS PF, PI, and Dep, whereas those who underwent an open subpectoral approach showed significant improvement in PF and PI but not Dep. Our findings suggest there may be a slight benefit for patients who undergo arthroscopic tenodesis when compared a subpectoral open approach. However, no significant differences were found between the two cohorts for PROMIS or the time to reach MCID. Therefore, suggesting the modality of bicep tenodesis with concomitant ARCR does not impact patient outcomes at 6-month follow-up. [Table: see text][Table: see text][Table: see text]

Diagnostic performance for severity grading of hip osteoarthritis and osteonecrosis of femoral head on radiographs: Deep learning model vs. board-certified orthopaedic surgeons

ObjectivesTo evaluate the diagnostic performance of a single deep learning (DL) model for severity grading of two typical yet challenging hip disorders, primary hip osteoarthritis (PHOA) and osteonecrosis of the femoral head (ONFH), on digital radiography. DesignWe conducted a two-center, retrospective study. We trained an XceptionNet-based DL model using a dataset consisting of 56,597 hip images diagnosed as normal, PHOA_I, PHOA_II, PHOA_III, and ONFH_II, ONFH_III, ONFH_IV by a panel of 10 board-certified orthopedic surgeons. The trained model was validated on a separate testing dataset. To demonstrate the model's generalizability, we applied the trained model directly to a dataset consisting of 811 hip images collected from an external clinical center. ResultsAccuracy, area under the curve (AUC) of receiver operating characteristics, sensitivity, and specificity were investigated. Validated on the testing dataset, the model achieved an overall AUC of 94.9%, with individual AUC scores of 94.2% for PHOA_I, 95.8% for PHOA_II, 90.9% for PHOA_III, 93.6% for ONFH_II, 93.8% for ONFH_III, and 93.8% for ONFH_IV. The average sensitivity for all classes of the DL algorithm (0.797) was better than the average level of the board-certified orthopedic surgeons (0.756). When applied directly to the external dataset, the AUC of the trained model is degraded. ConclusionWe can train a single DL model to grade the severity of PHOA and ONFH on digital radiographs. The model may be used to provide a second opinion for severity grading of hip disorders on digital radiographs.

Cervical Spinal Immobilization: A Head-to-Head Comparison of a One-Step Spray-on Foam Splint Versus Structural Aluminum Malleable Splint Immobilization.

Cervical spine immobilization in a low-resource environment is difficult secondary to limited equipment, prolonged transportation, and secondary complications. A structural aluminum malleable (SAM) splint is commonly utilized because of its availability and multipurpose intention. A one-step spray-on foam immobilization technique (Fast Cast) has been shown to be effective in lower-extremity splinting. The aim of this study was to demonstrate the ability of the Fast Cast to effectively immobilize the cervical spine in a head-to-head comparison against the SAM splint. We hypothesized that there would be no difference in surgeon scoring between Fast Cast and SAM splints for the immobilization of the cervical spine. This was a cadaveric experimental comparative study that compared a SAM splint versus Fast Cast for the immobilization of an unstable cervical spine. Each of the three cadaveric specimens had a corpectomy without fixation performed. A board-certified emergency medicine physician specialized in disaster medicine performed all SAM immobilizations. An orthopedic surgeon performed Fast Cast immobilizations. Each method of immobilization was done on each cadaver. Lateral fluoroscopic imaging was taken before and after immobilization and after log roll/gravity stress. Five board-certified orthopedic surgeons served as graders to independently score each splint. A 5-point Likert scale based on 10 splinting criteria (50 total points possible) was utilized to evaluate cervical spine immobilization. The lead statistical analyst was blinded to the immobilization groups. The statistical significance was assessed via a Wilcoxon signed-rank test and chi-square Fisher's exact test with significance between groups set at α < .05. Inter-rater reliability of the Likert scale results was assessed with the interclass correlation coefficient. Inter-rater reliability for the current Likert scale in the evaluation of cervical spine stabilization was good (interclass correlation coefficient = 0.76). For the cumulative Likert scale score, Fast Cast (32 [28-34]) exhibited a higher total score than SAM (44 [42-47]; P < .01). Likewise, Fast Cast exhibited a greater likelihood of higher Likert scores within each individual question as compared to SAM (P ≤ 0.04). In 100% of cases, raters indicated that Fast Cast passed the gravity stress examination without intrinsic loss of reduction or splinting material, whereas 33% of SAM passed (P < .01). In 100% of cases, raters indicated that Fast Cast passed the initial radiographic alignment following immobilization, whereas 66% of SAM passed (P = .04). In 100% of cases, raters indicated that Fast Cast passed radiographic alignment after the gravity stress examination, whereas 47% of SAM passed (P < .01). The Fast Cast exceeded our expectations and was shown to be rated not equivalent but superior to SAM splint immobilization for the cervical spine. This has significant clinical implications as the single-step spray-on foam is easy to transport and has multifaceted applications. It also eliminates pressure points and circumferential wrapping and obstruction to airway/vascular access while immobilizing the cervical spine and allowing for radiographic examination. Further studies are needed for human use and application.

Increased Medial Femoral Condyle Angle and Narrow Intercondylar Notch Are Associated With Medial Meniscus Posterior Root Tear

To investigate the correlation between nontraumatic medial meniscus posteriorroot tear (MMPRT) and bone morphology of the knee with a particular emphasis on MMPR impingement. Magnetic resonance imaging (MRI) findings were examined between January 2018 and December 2020. MRI findings of patients with traumatic MMPRT, Kellgren Lawrence stage 3-4 arthropathy on radiographs, single- or multiple-ligament injuries and/or those who underwent treatment for these diseases, and surgery in and around the knee were excluded from the study. MRI measurements included medial femoral condylar angle (MFCA), intercondylar distance (ICD), and intercondylar notch width (ICNW), distal/posterior medial femoral condylar offset ratio, notch shape, medial tibial slope (MTS) angle, and medial proximal tibial angle (MPTA) measurements and spur presence and were compared between groups. All measurements were performed by two board-certified orthopedic surgeons on a best agreement basis. MRI examinations of patients aged 40-60 were analyzed. MRI findings were divided into two groups: the study group of MRI findings of patients with MMPRT (n= 100) and the control group of MRI findings of patients without MMPRT (n= 100). MFCA was found to be significantly higher in the study group (mean: 46.5 ± 3.58) than in the control group (mean: 40.04 ± 4.61) (P < .001). In the study group, the ICD (study group mean: 76.26 ± 4.89; control group mean: 78.18 ± 6.1) was significantly narrower (P= .018), and the ICNW (study group mean: 17.19 ± 2.23; control group mean: 20.48 ± 2.13) was significantly shorter (P < .001). The ICNW/ICD ratio was significantly lower in patients in the study group (0.22 ± 0.02) than in the control group (0.25 ± 0.02) (P < .001). Bone spurs were present in 84% of the study group and only in 28% of those in the control group. In the study group, the most common notch type was A-type with 78%, while the least common was the U-type notch with 10%. However, in the control group, the most common notch type was A-type with 43%, and the least common was the W-type notch with 22%. The distal/posterior medial femoral condylar offset ratio was statistically lower in the study group (0.72 ± 0.07) than in the control group 0.78 ± 0.07) (P < .001). No significant intergroup differences were found in MTS (study group mean: 7.51 ±2.59; control group mean: 7.83 ± 2.57) (P= .390) and MPTA (study group mean: 86.92 ±2.15; control group mean: 87.48 ±1.8) measurements (P=.67). Increased medial femoral condylar angle, low distal/posterior femoral offset ratio, narrow intercondylar distance and intercondylar notch width, A-type notch shape, and spur presence are associated with MMPRT. Level III, retrospective cohort study.

Distal Radius Fracture Management: Surgeon Factors Markedly Influence Decision Making.

It is our hypothesis that physician-specific variables affect the management of distal radius (DR) fractures in addition to patient-specific factors. A prospective cohort study was conducted evaluating treatment differences between Certificate of Additional Qualification hand surgeons (CAQh) and board-certified orthopaedic surgeons who treat patients at level 1 or level 2 trauma centers (non-CAQh). After institutional review board approval, 30 DR fractures were selected and classified (15 AO/OTA type A and B and 15 AO/OTA type C) to create a standardized patient data set. The patient-specific demographics and surgeon's information regarding the volume of DR fractures treated per year, practice setting, and years posttraining were obtained. Statistical analysis was done using chi-square analysis with a postanalysis regression model. A notable difference was observed between CAQh and non-CAQh surgeons. Surgeons in practice longer than 10 years or who treat >100 DR fractures/year were more likely to choose surgical intervention and obtain a preoperative CT scan. The two most influential factors in decision making were the patients' age and medical comorbidities, with physician-specific factors being the third most influential in medical decision making. Physician-specific variables have a notable effect on decision making and are critical for the development of consistent treatment algorithms for DR fractures.

OF spine classification of osteoporotic thoracolumbar vertebral body fractures by MRI and conventional radiographs only leads to high inter-observer agreement rates-an additional CT adds limited information for the of classification and the OF score

ObjectivesThe purpose of this study was to investigate whether the addition of computed tomography (CT) to magnetic resonance imaging (MRI) improves the accuracy of classifying osteoporotic vertebral body fractures (OVBF).MethodsA retrospective analysis of a prospective single-center database has been performed. All consecutive patients who had suffered an acute thoracolumbar OVBF in one level II spine center between 2017 and 2019 were analyzed. Thereby, fractures of type OF 1 and OF 5 were excluded. All fractures were initially classified by 5 board-certified orthopaedic surgeons based on MRI and conventional radiographs. Afterwards a reclassification including CT scans were performed. Differences in OF classification and OF score values between both measurements were analyzed.ResultsA total of 61 patients were analyzed with a mean age 75.8 years (SD: 8.8 years). In 82.9% of the cases, there was no difference in OF classification comparing classification based only on MRI versus MRI + CT. A difference of more than two OF types was observed in less than 1% of all ratings. The inter-rater reliabilities of the OF classification based on CT + MRI and MRI alone were 0.63 and 0.49, respectively. In 97.5% of the cases there was no therapy-relevant difference of the treatment recommendation with respect of a surgical or nonoperative treatment recommendation based on the OF score.ConclusionIn terms of the OF classification and the OF score, the addition of CT add limited value compared to conventional radiographs and MRI only. Additionally, there is only a minor rate of disagreement in treatment recommendations when adding a CT.

Epidemiology of MRI-detected muscle injury in athletes participating in the Tokyo 2020 Olympic Games

ObjectiveMuscle injury is one of the most common injuries occurring at the Olympic Games often with devastating consequences. Epidemiological injury surveillance is recognised by the IOC as essential for injury...

Artificial intelligence-based computer-aided system for knee osteoarthritis assessment increases experienced orthopaedic surgeons’ agreement rate and accuracy

PurposeThe aims of this study were to (1) analyze the impact of an artificial intelligence (AI)-based computer system on the accuracy and agreement rate of board-certified orthopaedic surgeons (= senior readers) to detect X-ray features indicative of knee OA in comparison to unaided assessment and (2) compare the results to those of senior residents (= junior readers).MethodsOne hundred and twenty-four unilateral knee X-rays from the OAI study were analyzed regarding Kellgren–Lawrence grade, joint space narrowing (JSN), sclerosis and osteophyte OARSI grade by computerized methods. Images were rated for these parameters by three senior readers using two modalities: plain X-ray (unaided) and X-ray presented alongside reports from a computer-assisted detection system (aided). After exclusion of nine images with incomplete annotation, intraclass correlations between readers were calculated for both modalities among 115 images, and reader performance was compared to ground truth (OAI consensus). Accuracy, sensitivity and specificity were also calculated and the results were compared to those from a previous study on junior readers.ResultsWith the aided modality, senior reader agreement rates for KL grade (2.0-fold), sclerosis (1.42-fold), JSN (1.37-fold) and osteophyte OARSI grades (3.33-fold) improved significantly. Reader specificity and accuracy increased significantly for all features when using the aided modality compared to the gold standard. On the other hand, sensitivity only increased for OA diagnosis, whereas it decreased (without statistical significance) for all other features. With aided analysis, senior readers reached similar agreement and accuracy rates as junior readers, with both surpassing AI performance.ConclusionThe introduction of AI-based computer-aided assessment systems can increase the agreement rate and overall accuracy for knee OA diagnosis among board-certified orthopaedic surgeons. Thus, use of this software may improve the standard of care for knee OA detection and diagnosis in the future.Level of evidenceLevel II.

Deep Learning Assistance Closes the Accuracy Gap in Fracture Detection Across Clinician Types.

Missed fractures are the most common diagnostic errors in musculoskeletal imaging and can result in treatment delays and preventable morbidity. Deep learning, a subfield of artificial intelligence, can be used to accurately detect fractures by training algorithms to emulate the judgments of expert clinicians. Deep learning systems that detect fractures are often limited to specific anatomic regions and require regulatory approval to be used in practice. Once these hurdles are overcome, deep learning systems have the potential to improve clinician diagnostic accuracy and patient care. This study aimed to evaluate whether a Food and Drug Administration-cleared deep learning system that identifies fractures in adult musculoskeletal radiographs would improve diagnostic accuracy for fracture detection across different types of clinicians. Specifically, this study asked: (1) What are the trends in musculoskeletal radiograph interpretation by different clinician types in the publicly available Medicare claims data? (2) Does the deep learning system improve clinician accuracy in diagnosing fractures on radiographs and, if so, is there a greater benefit for clinicians with limited training in musculoskeletal imaging? We used the publicly available Medicare Part B Physician/Supplier Procedure Summary data provided by the Centers for Medicare & Medicaid Services to determine the trends in musculoskeletal radiograph interpretation by clinician type. In addition, we conducted a multiple-reader, multiple-case study to assess whether clinician accuracy in diagnosing fractures on radiographs was superior when aided by the deep learning system compared with when unaided. Twenty-four clinicians (radiologists, orthopaedic surgeons, physician assistants, primary care physicians, and emergency medicine physicians) with a median (range) of 16 years (2 to 37) of experience postresidency each assessed 175 unique musculoskeletal radiographic cases under aided and unaided conditions (4200 total case-physician pairs per condition). These cases were comprised of radiographs from 12 different anatomic regions (ankle, clavicle, elbow, femur, forearm, hip, humerus, knee, pelvis, shoulder, tibia and fibula, and wrist) and were randomly selected from 12 hospitals and healthcare centers. The gold standard for fracture diagnosis was the majority opinion of three US board-certified orthopaedic surgeons or radiologists who independently interpreted the case. The clinicians' diagnostic accuracy was determined by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve, sensitivity, and specificity. Secondary analyses evaluated the fracture miss rate (1-sensitivity) by clinicians with and without extensive training in musculoskeletal imaging. Medicare claims data revealed that physician assistants showed the greatest increase in interpretation of musculoskeletal radiographs within the analyzed time period (2012 to 2018), although clinicians with extensive training in imaging (radiologists and orthopaedic surgeons) still interpreted the majority of the musculoskeletal radiographs. Clinicians aided by the deep learning system had higher accuracy diagnosing fractures in radiographs compared with when unaided (unaided AUC: 0.90 [95% CI 0.89 to 0.92]; aided AUC: 0.94 [95% CI 0.93 to 0.95]; difference in least square mean per the Dorfman, Berbaum, Metz model AUC: 0.04 [95% CI 0.01 to 0.07]; p < 0.01). Clinician sensitivity increased when aided compared with when unaided (aided: 90% [95% CI 88% to 92%]; unaided: 82% [95% CI 79% to 84%]), and specificity increased when aided compared with when unaided (aided: 92% [95% CI 91% to 93%]; unaided: 89% [95% CI 88% to 90%]). Clinicians with limited training in musculoskeletal imaging missed a higher percentage of fractures when unaided compared with radiologists (miss rate for clinicians with limited imaging training: 20% [95% CI 17% to 24%]; miss rate for radiologists: 14% [95% CI 9% to 19%]). However, when assisted by the deep learning system, clinicians with limited training in musculoskeletal imaging reduced their fracture miss rate, resulting in a similar miss rate to radiologists (miss rate for clinicians with limited imaging training: 9% [95% CI 7% to 12%]; miss rate for radiologists: 10% [95% CI 6% to 15%]). Clinicians were more accurate at diagnosing fractures when aided by the deep learning system, particularly those clinicians with limited training in musculoskeletal image interpretation. Reducing the number of missed fractures may allow for improved patient care and increased patient mobility. Level III, diagnostic study.

Poster 158: Does an In-Situ Biceps Tenodesis with an Anatomic Length-Tension Relationship affect the Incidence of Popeye Deformity and Clinical Outcomes Compared to an Estimated Length-Tension Relationship Technique?

Objectives:Biceps Popeye deformity is a common finding with rupture of the long head of the biceps tendon (LHBT), biceps tenodesis failure or length-tension mismatch during tenodesis. The Popeye muscle is a cosmetic deformity of the arm that may be accompanied by cramping and muscle fatigue and many patients are dissatisfied with the symptoms and appearance. Although prior studies have described physiologic landmarks to optimize the length-tension relationship during biceps tenodesis after LHBT rupture, no study has assessed the biceps muscle appearance after tenodesis “in-situ” prior to the release of the LHBT from the superior labrum for biceps tendon pathologies without complete rupture. Therefore, the purpose of this study is to assess clinical outcomes of an all-arthroscopic technique for biceps tenodesis which maintains the anatomic length-tension relationship of the LHBT prior to tenotomy from the superior labrum. We compared this group of patients to a control group of patients who underwent an interference screw tenodesis technique that required cutting the LHBT from the superior glenoid prior to tenodesis with an estimation of the anatomic length-tendon relationship potentially contributing to subtle biceps Popeye deformity. We hypothesize that an “in-situ” anatomic length-tension relationship tenodesis technique would reduce the risk of a Popeye deformity, reduce cramping and muscle fatigue, and have improved patient-reported outcome measures compared to an estimated length-tension relationship tenodesis with an interference screw.Methods:Consecutive patients who underwent arthroscopic biceps tenodesis with concomitant rotator cuff procedures were enrolled in this study from 2019-2021 and patients were grouped based on a change in senior author’s tenodesis technique, with the initial cohort having an arthroscopic interference screw subpectoral biceps tenodesis after tenotomy from the superior labrum in an “estimated” length-tension relationship technique (Group 1), and the later cohort having an arthroscopic suprapectoral biceps tenodesis “in-situ” with an anatomic length-tension relationship (Group 2) with the LHBT tied to the side of the humerus with all-suture unicortical anchors. Patients were assessed at a minimum of 3-month follow-up and asked about post-operative anterior arm pain and biceps muscle spasms, and if they notice any difference in appearance between their bicep muscles on a 4-point Likert scale (none, mild, moderate, severe). Patient-Reported Outcomes (PROs) of Veterans-Rand 12, American Shoulder and Elbow Score (ASES), EuroQol- 5 Dimension (EQ-5D), PROMIS 10, and Single Assessment Numeric Evaluation (SANE) were collected. Bilateral bicep images of participants were taken in three forearm positions with the elbow flexed 90 degrees: (1) maximal supination, (2) neutral, and (3) maximal pronation. Review of pronation, supination, and neutral forearm rotation bilateral biceps images were evaluated, after blinding and de-identification, by two shoulder and elbow fellowship-trained board-certified orthopedic surgeons for visual appearance and grade of Popeye deformity (none, mild, obvious Popeye). Non-parametric between-group comparison and analysis were performed with statistical significance set at p < 0.05.Results:Sixty-two patients (53% female, age 58.7 ± 9.0 years) were enrolled (33 in Group 1 and 29 in Group 2) with a mean follow-up of 9.8 ± 6.5 months. There were no significant differences between groups with respect to gender, age, and laterality of biceps tenodesis, as well as type and size of rotator cuff repair. There were no significant differences in ASES, EQ5D, and SANE scores between the two technique groups. However, PROMIS 10 Physical Health Scores were significantly improved in Group 2 (15.7 ± 2.3) compared to Group 1 (14.4 ± 2.9) (p=0.03). Patients in Group 2 experienced significantly less pain in their anterior arm than patients in Group 1 (19% vs. 33%, p=0.02) however there were no differences in biceps muscle spasm (3.4% vs. 5.2%, p=0.21). There also were no significant differences in patient-perceived biceps deformity between Group 1 (17.2%) and Group 2 (27%) (p=0.26). Similarly, there were no significant differences in surgeon-perceived biceps deformity between Group 1 and Group 2 (30.3% vs. 24.1%, p=0.47). Interrater reliability for surgeon assessment of a Popeye deformity was found to have a substantial agreement with a Kappa value of 0.77 (p <.0.001), 95% CI (0.645, 0.855).Conclusions:An arthroscopic suprapectoral biceps tenodesis performed “in-situ” with an anatomic length-tension relationship did not reduce the incidence of patient or surgeon perceived Popeye muscle deformity compared to an interference screw tenodesis performed after tenotomy in an “estimated” length-tension relationship technique. Interestingly, the “in-situ” length-tension technique reduced anterior arm pain and improved PROMIS 10 physical health scores post-operatively compared to the “estimated” interference screw technique.

Supine Knee Positioning Does Not Interfere with Mobile-Bearing Unicompartmental Knee Arthroplasty Performance.

The Food and Drug Administration has only approved mobile-bearing unicompartmental knee arthroplasty (MB-UKA) to be performed with a hanging leg holder. The purpose of this study is to evaluate the impact of a supine knee position on MB-UKA performance.In total, 16 cadavers were randomized so that either the right or left knee was placed in the flexed or supine positions. One board-certified orthopaedic surgeon and three adult reconstruction fellows that attended the required Oxford partial knee instructional course performed four operations in each position. The primary outcome was final knee balance. Secondary outcomes included procedure duration, timing of individual surgical steps, implant sizes, range of motion, implant alignment, and fracture. A Students t-test was used to examine differences between positions with significance set at p < 0.05. Secondary analyses using two one-sided tests were conducted to explore equivalence between the two positions.There was no significant difference in mean final balance between supine (1.7 mm ± standard deviation [SD] = 1.5 mm) and flexed (1.3 ± 1.3 mm) positions (p = 0.390). There were also no significant differences between positions for procedure time (p = 0.497), tibia coronal alignment (p = 0.614), tibial slope (p = 0.194), femoral component sagittal alignment (p = 0.091), and fractures (n = 0). Exploratory equivalence analyses indicated that the positions were equivalent for final balance (p = 0.002).MB-UKA performed in the supine position is not significantly different from the flexed position in terms of ligament balance, overall procedure time, and radiographic appearance. These initial safety data warrant further clinical investigations and support the expansion of the surgical technique to include performing MB-UKAs in the supine position.

Anthropometric three-dimensional computed tomography reconstruction measurements of the acetabulum in children/adolescents.

The key element for differentiation between normal anatomical variants and pathological deformities is the prior definition of normal ranges for anthropometric parameters of acetabulum according to each age group. Aim of the present study is to analyze the development of the acetabulum in children/adolescents by accurate anthropometric measurements using 3D-CT scans and determine the variations occurring depending on age, gender and/or side. This retrospective observational study included 85 patients (170 hips) under 15 years of age (0-15) undergoing 1.5mm CT scanning for non-hip related reasons. The measurements were performed by 2 board-certified orthopaedic surgeons. Each year of life represented an age group forming a total of 16 groups. Median number of patients per age group was 12 (range 4-16). The anthropometric parameters included acetabular volume, inclination, version, depth (coronal and axial), width (coronal and axial), Tönnis angle as well as anterior and posterior acetabular sector angles. Mean values, range, standard deviation, p-values, intra- and interrater reliability were calculated. All measurement values correlated significantly with age. Statistically, there was no side or gender related difference. Rapid growth phases were observed at the age of 11-12. The inter- and intrarater reliability was high (range ICC 0.8-0.99, Cronbach alpha 0.86-0.99, Bland-Altman good agreement). The present data provides age- and gender-related normative values as well as growth phases describing acetabular morphology. It should help paediatricians as well as paediatric and orthopaedic surgeons as a tool for early diagnosis of deformity and guidance for possible procedures.

Industry Payment Trends to Orthopaedic Surgeons From 2014 to 2018: An Analysis of the First 5 Years of the Open Payments Database.

The Open Payments Database (OPD) provides transparent reporting of all payments made to physicians from private industry. Previous studies have described the nature of these financial relationships using the first year of publicly available data. However, long-term trends of these relationships have not been well described. Therefore, we report on the value and distribution of payments within the OPD and analyze trends of payments made to orthopaedic surgeons from 2014 to 2018. The OPD was queried from 2014 to 2018. Payments within the database were categorized into (1) general payments, (2) research interests, and (3) ownership interests. We report on the number, value, and payment trends between private industry and all licensed orthopaedic surgeons who have completed residency training. A total of 631,000 physicians and 23,859 orthopaedic surgeons were included, representing 79.8% of US board-certified orthopaedic surgeons (n = 29,908). Although orthopaedic surgeons received an average of 2.9% of the number of payments made annually, payments to orthopaedic surgeons represented 10.0% of the value of payments made to all physicians. From 2014 to 2018, payments to orthopaedic surgeons increased in both number and value, from 313,194 separate payments ($883.8 million) in 2014 to 335,815 separate payments ($958.6 million) in 2018. In 2018, the top 1% of orthopaedic surgeons (n = 239) accounted for 58.0% ($265.8 million) of all payments to the field. Despite representing only 2.4% of the number of general payments, royalties represented 68.9% ($290.4 million) of the value of general payments to orthopaedic surgeons. Payments for research and education both increased. Industry payments to orthopaedic surgeons represent 10.0% of all physician payments, with increases in payments for research and education. Royalties represented most (68.9%) of the value of general payments made to orthopaedic surgeons. Transparency in physician payments from industry is essential to avoid conflicts of interest. Level III.