Description Of Levels Research Articles

Disparities in Rotator Cuff Tear Progression Definitions and Rates: A Systematic Review.

While rotator cuff tears are prevalent in the general population, the natural history of this disease is unclear. Understanding rotator cuff tear progression is crucial for refining surgical indications and evaluating the necessity of early interventions. This study presents an in-depth analysis of the existing literature on the definitions and progression rates of rotator cuff tears, aiming to enhance clinical decision making and patient outcomes. A systematic literature search was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using Medline (PubMed), Embase (Elsevier), and Web of Science databases on January 12, 2023. Articles were identified as relevant to the natural history and progression of asymptomatic and symptomatic partial-thickness (PT) and full-thickness (FT) rotator cuff tears. Those written in English reporting rotator cuff progression rates of tears in adults, based on magnetic resonance imaging (MRI) or ultrasound, were included. After reviewing the articles, the data on the rates of tear progression and associated risk factors were extracted, compiled, and analyzed. The risk of bias was determined using the Newcastle-Ottawa Scale. Twenty-one articles met the inclusion criteria, with 1,831 tears included. The progression rate for all partial thickness tears was 26.7% ± 12.8% at an average follow-up of 2.2 ± 0.9 years, with 5 definitions for tear progression. For FT tears, the progression rate was 54.9% ± 18.6% at a follow-up time of 3.0 ± 2.0 years, with 8 definitions for tear enlargement. A significant difference (p < 0.0001) was found between the progression rates of PT and FT tears. Patients who were initially asymptomatic and became symptomatic had higher progression rates (33%-63%) than those who remained asymptomatic (4%-38%). Further research would benefit by identifying a clinically relevant and standardized definition of rotator cuff tear progression, to describe the natural history of rotator cuff disease, making results more comparable and optimizing treatment planning. Level II. See Instructions for Authors for a complete description of levels of evidence.

Transfemoral Osseointegration for Amputees with Well-Managed Diabetes Mellitus

Background: The most common reason for lower-extremity amputations remains the management of complications of diabetes mellitus (DM) and/or peripheral vascular disease. Traditional socket prostheses remain the rehabilitation standard, although transcutaneous osseointegration for amputees (TOFA) is proving a viable alternative. Limited studies of TOFA for vascular amputees have been published, but no study has focused on TOFA for patients with DM, neglecting this important patient population. The primary aim of the present study exploring this potential care option was to report the frequencies and types of adverse events following TOFA for patients with well-controlled DM. The secondary aims were to report their mobility and quality-of-life changes. Methods: A retrospective review was performed of 17 consecutive patients with well-controlled DM who had undergone unilateral transfemoral TOFA from 2013 to 2019 and had been followed for at least 2 years. Outcomes were perioperative complications, additional surgery (soft-tissue refashioning, debridement, implant removal, periprosthetic fracture treatment), mobility (daily prosthesis wear hours, K-level, Timed Up and Go Test, 6-Minute Walk Test), and patient-reported outcomes (Questionnaire for Persons with a Transfemoral Amputation, Short Form-36). Results: There were no perioperative systemic complications, deaths, or proximal amputations. Two patients (12%) sustained a periprosthetic fracture following a fall, managed by internal fixation with implant retention, and regained independent ambulation. Eight patients (47%) had additional surgery or surgeries for non-traumatic complications: 4 (24%) had soft-tissue refashioning, 3 (18%) had debridement, and 3 others had implant removal with subsequent revision osseointegration for aseptic loosening (1) or infection (2). The proportion of patients wearing their prosthesis at least 8 hours daily improved from 5 (36%) to 11 (79%) of 14 (p = 0.054). The proportion of patients who achieved at least K-level 2 improved from 6% to 94% (p &lt; 0.001). Other changes were not significant. Conclusions: Contraindicating TOFA for all patients with DM seems draconian. Patients with well-controlled DM experienced significant mobility improvements, although additional surgery was somewhat common. Improvements in selection criteria or surgical technique to reduce risks are needed so that TOFA can be routinely considered for amputees with well-controlled DM. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Factors Associated with Unsuccessful Revascularization Surgery in Traumatic Upper-Extremity Amputation.

Microsurgical emergency revascularization surgery for traumatic upper-extremity amputations demands high resource use. Injury details and patient characteristics influence the decision of whether to revascularize or revise an amputation involving the upper extremity. Our aim was to study associations between those factors and unsuccessful revascularization to provide information for clinical decision-making regarding amputation injuries. We studied all consecutive patients who had undergone an upper-extremity revascularization at Tampere University Hospital between 2009 and 2019. The primary outcome was the technical success or failure of the operation, which was defined as the survival or non-survival of the amputated tissue. Using logistic regression, we analyzed prognostic factors including age, sex, smoking status, diabetes mellitus, injury mechanism (cut, crush, or avulsion), extent of tissue loss before treatment (number of lost joints), and amputation type (total or subtotal). A total of 282 patients (mean age, 47 years; 14% female; mostly White Caucasian) were included. The proportion of successful revascularizations (survival of all reconstructed tissue) was 76% (214 of 282). An avulsion injury mechanism (adjusted odds ratio [aOR], 5.9; 95% confidence interval [CI], 2.5 to 14.2), crush injury mechanism (aOR, 2.8; 95% CI, 1.1 to 7.0]), and total amputation type (aOR, 2.9; 95% CI, 1.5 to 5.8) were the prognostic factors that were associated with the highest risk of unsuccessful revascularizations. We found an S-shaped, nonlinear association between patient age and unsuccessful revascularizations and a U-shaped, nonlinear association between the amount of tissue loss before treatment and unsuccessful revascularizations. There was no evidence of an association between unsuccessful revascularizations and patient sex, smoking, or diabetes mellitus. Injury details were the most significant prognostic factors of an unsuccessful upper-extremity revascularization, while age was the only patient characteristic that was associated with this outcome. In particular, total amputation type and avulsion and crush injury mechanisms yielded a higher risk of unsuccessful revascularization. We recommend considering this information when making decisions regarding the treatment of upper-extremity amputation injuries. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Disparities in Access to and Utilization of Surgical Care for Patients with Closed Unstable AO/OTA 44B2 Ankle Fractures and Medicaid.

Closed, unstable AO/OTA 44B2 ankle fractures are common injuries with similar distributions by age, sex, and race. The purpose of this study was to identify disparities in access to and utilization of surgical care for these injuries. Ambulatory patients ≥18 years of age with capitated Medicaid health insurance who presented from January 2016 to February 2020 with an isolated, closed AO/OTA 44B2 ankle fracture with radiographic evidence of instability were retrospectively identified at 1 Level-I safety-net trauma center. Associations between patient characteristics (age, sex, preferred language, race, ethnicity, housing status, employment, and substance use) and measures of access to and utilization of ankle fracture surgery (days from injury to evaluation, being offered surgery, undergoing surgery, and days from evaluation to surgery) were investigated on bivariable and multivariable analysis. Of the 1,116 patients who were screened, 323 met the inclusion criteria. The included patients had a median age of 41 years; 207 patients (64%) were male and 255 (79%) were Hispanic. Patients presented at a mean of 4.6 ± 7.0 days from injury. Delayed presentation was associated with self-identification as Hispanic (rate ratio [RR], 1.93; 95% confidence interval [CI]: 1.17, 3.12]) and with marijuana use (RR, 1.59; 95% CI: 1.08, 2.36), whereas significantly earlier presentation was associated with a non-English language preference (RR, 0.64; 95% CI: 0.46, 0.89), alcohol abuse (RR, 0.74; 95% CI: 0.55, 0.99), and illicit drug use (RR, 0.30; 95% CI: 0.14, 0.67). Ankle fracture surgery was offered to 274 patients (85%). Experiencing homelessness was associated with a decreased likelihood of being offered surgery (odds ratio [OR], 0.15; 95% CI: 0.03, 0.69). Of patients who were offered surgery, 216 (79%) underwent surgery. Black patients underwent surgery significantly less frequently than patients who identified as White (OR, 0.14; 95% CI: 0.01, 0.77). The median time from evaluation to surgery was 11 days (interquartile range, 7 to 14 days). Patients who used illicit drugs experienced a mean delay to surgery of 6.0 days relative to those who did not use illicit drugs (mean time to surgery, 16.8 ± 7.1 and 10.8 ± 5.1 days, respectively). We identified disparities in access to and utilization of surgical care for unstable AO/OTA 44B2 ankle fractures that negatively affected patients with Medicaid insurance who identified as Hispanic or Black, were experiencing homelessness, or used illicit drugs. These disparities may negatively affect outcomes for patients receiving care in similar environments, such as capitated health-care networks and public safety-net health systems. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical and Radiographic Outcomes in Kienbock Disease Following Radial Closing Wedge Osteotomy: An Age Comparative Study and Literature Review.

Age is a preoperative prognostic factor for radial closing wedge osteotomy (RCWO) in Kienbock disease. Specifically, for cases classified as Lichtman stage III, clear criteria for selecting RCWO have not been established. We believe that age can provide vital information for determining the appropriate surgical procedure for Kienbock disease. The aim of this study was to investigate RCWO outcomes for Lichtman stage III by examining different age groups from clinical and radiological perspectives. Sixteen patients with Lichtman stage III Kienbock disease underwent RCWO. The median age was 59 years, and the median follow-up period was 2.9 years. We determined the age cutoffs for clinical and radiological outcomes using a receiver operating characteristic curve. Subsequently, we conducted intergroup comparisons of postoperative outcomes between the younger and older age groups. Age cutoffs were established at 52.5 and 30 years for clinical and radiological outcomes, respectively. In the comparative analysis, the younger age group (≤52 years; n = 7) demonstrated significantly superior clinical results, including improved range of motion and pain relief, higher postoperative Mayo Wrist Score, and lower Disability of the Arm, Shoulder, and Hand scores. From a radiological perspective, the younger age group (≤30 years; n = 3) experienced segmented lunate bone fragments healing, indicating an improved disease stage compared with the older group. Based on previous literature and our research findings, it is reasonable to conclude that RCWO results in improved clinical outcomes for patients up to their mid-50s and enhanced radiological outcomes for those up to approximately at the age of 30 years. Further studies on these age cutoffs will contribute to refining the surgical selection criteria for RCWO. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effective Compression and a Minimally Invasive Rail Plate to Optimize Bone Transport in Distraction Osteogenesis: New Concepts.

Bone transport in distraction osteogenesis is an effective, well-known procedure. However, bone compression is an aspect of this technique for which there is no objective information. The lack of direct bone compression measurements may result in a lack of uniformity in the bone transport process, which can result in its ineffective application and may be contributing to its underutilization. This study describes the results of applying objectively measured compressions to achieve a distraction regeneration zone and docking site consolidation during bone transport in distraction osteogenesis. This prospective study describes the results of a single cohort of 32 patients who underwent distraction osteogenesis with bone transport utilizing a combination of a minimally invasive rail plate and monolateral external fixation. The patients were categorized into 2 groups: (1) those with hypertrophic, atrophic, or infectious pseudarthrosis-nonunion (the pseudarthrosis-nonunion group), and (2) those with bone loss due to trauma or osteomyelitis (the bone loss group). The initial bone compression was measured during the latency phase, and the final compression was measured during the distraction phase. The healing index, external fixation index, healing time, consolidation time, and docking time were calculated for each patient. The Mann-Whitney U and Kruskal-Wallis tests were used for comparisons between and within groups. In this study, 28 (88%) of the patients were male. The mean patient age was 44.93 ± 16.21 years. The median values were 3.2 Nm for the initial compression and 3.4 Nm for the final compression, with no significant difference between or within groups of patients. The osseous results were excellent in 29 patients (91%), and the functional results were good or excellent in 31 patients (97%). This study is the first to objectively measure compression in the bone transport process. Our findings showed that all patients who had an initial compression of ≥3.2 Nm achieved 100% consolidation of the distraction regeneration zone, and those who had a final compression of ≥2.9 Nm achieved complete docking site consolidation without complications. These 2 values thus represent effective compression and highlight the role of bone compression in bone transport. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Incidence of Ipsilateral Femoral Neck and Shaft Fractures in Pediatric and Adolescent Patients

OBJECTIVES: To identify the incidence, patient characteristics, and effectiveness of radiographic screening methods for detecting ipsilateral femoral neck and shaft fractures in pediatric and adolescent trauma patients. METHODS: Design: Retrospective cohort study. Setting: This study was conducted at a tertiary pediatric trauma hospital. Patient Selection Criteria: Patients younger than 18 years treated for a femoral shaft fracture between 2004 and 2018 were reviewed. Pathologic (metabolic bone disease or bone lesion), periprosthetic, and penetrating traumatic femoral shaft fractures were excluded. Outcome Measurements and Comparisons: Patient demographics, mechanisms of injury, treatment methods, and associated injuries were analyzed. Pretreatment x-rays and computed tomography (CT) scans were reviewed for the identification of ipsilateral femoral neck and shaft fractures. RESULTS: Among the 840 pediatric patients included in this study, 4 patients (0.5%) sustained ipsilateral femoral neck and shaft fractures. All the femoral neck fractures were observed in adolescents (aged 13–17 years) and involved in high-energy traumas. In adolescents involved in high-energy trauma, the incidence increased to 1.7%. Pretreatment sensitivity of both x-rays and CT scans was only 50% for the detection of femoral neck fractures. CONCLUSIONS: This study reveals that ipsilateral femoral neck and shaft fractures in pediatric patients are rare, occurring in adolescents involved in high-energy trauma. The findings suggest the need for a selective, rather than routine, use of CT scans based on the patient's age and the mechanism of injury. The use of alternative imaging methods such as magnetic resonance imaging should be considered to balance diagnostic accuracy while minimizing radiation exposure. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A 15-Year Bibliometric Analysis of Sports Medicine Studies in The Journal of Bone and Joint Surgery: A Systematic Review.

Orthopaedic sports medicine is among the most popular subspecialties. Understanding the trends in sports medicine research over time can offer insight into progress and innovation within the field. The purpose of this study was to assess both the quality of the current literature and trends in gender diversity and inclusion by evaluating publishing characteristics of sports medicine studies in The Journal of Bone and Joint Surgery-American Volume (JBJS-A) from 2007 to 2021. Sports medicine studies in JBJS-A from 2007 to 2021 were identified using JBJS subspeciality tags for "sports medicine" articles and organized by study type, number of authors, sex of the authors, academic degree(s) of the first and last authors, level of evidence, country of publication, citations, and use of patient-reported outcomes (PROM). A total of 784 studies were reviewed, and 513 met inclusion criteria. Clinical therapeutic studies were the most common publication (48%). There was an increase in the publication of clinical prognostic studies (17%-25%, p = 0.037) and a significant increase in the use of PROM measures over time (13%-47%, p < 0.001). The total number ofauthors increased over the study period (4.8-6.3), but there was no significant increase in female authorship. Only 15% of the 784 studies included a female author, with an average of 0.8 female authors per article (range 0-8) compared with 4.6 males (range 1-14). The significant increase in the use of PROMs in sports medicine studies indicates that the quality of research has improved over the 15-year period. The gender disparity in authorship has remained stagnant. Only 11% of all first authors and 9% of senior authors were female. The number of included international studies improved over time; however, the United States remains the most prolific publisher. Despite these areas of growth, this study suggests that there is room for improvement of authorship gender diversity in orthopaedic sports medicine research. Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparing Treatment Outcomes of Eligible Patients Consenting to or Declining Randomization in a Randomized Clinical Trial

Background: The Finnish Shaft of the Humerus (FISH) trial compared open reduction and internal plate fixation (ORIF) with functional bracing in adult patients with displaced, closed humeral shaft fractures. Here, we compare the results of the patients in the randomized clinical trial (RCT [the randomized cohort]) with those of the cohort of patients who were also eligible but declined randomization (the nonrandomized cohort) to investigate if patients’ treatment preference was associated with the outcomes during a 2-year follow-up. Methods: A total of 321 patients were treated at 2 university hospitals in Finland between November 2012 and January 2018. Of the 140 eligible patients, 82 were randomized to ORIF or functional bracing. Of the 58 patients declining randomization, 42 consented to participate in a nonrandomized cohort in which the patients were able to choose the treatment method. The primary outcome of this study was the Disabilities of the Arm, Shoulder and Hand (DASH) score. Patients in the randomized cohort and the nonrandomized cohort were analyzed separately in 3 groups: those who had (1) initial surgery, (2) successful functional bracing, and (3) late surgery due to failed functional bracing. We used mixed-model, repeated-measures analysis of variance to compare the treatment effect among the 3 groups. Results: In the randomized cohort, 38 patients had an initial surgical procedure. Of the 44 patients randomized to functional bracing, 30 (68%) healed successfully and 14 (32%) underwent a late surgical procedure. In the nonrandomized cohort, 9 patients preferred an initial surgical procedure. Of the 33 patients preferring functional bracing, 26 (79%) healed successfully and 7 (21%) underwent late surgery. The DASH scores in the randomized cohort and the nonrandomized cohort were 6.8 (95% confidence interval [CI], 2.3 to 11.4) and 12.3 (95% CI, 0.3 to 24.3) for the initial surgery groups, 6.0 (95% CI, 1.0 to 11.0) and 3.4 (95% CI, 0 to 9.3) for the bracing groups, and 17.5 (95% CI, 10.5 to 24.5) and 20.5 (95% CI, 9.4 to 31.6) for the late surgery groups at 2 years. Conclusions: The results of the randomized cohort and the nonrandomized cohort were comparable and suggest that patients’ treatment preferences are not associated with the treatment outcomes of these injuries. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Both-Bone Forearm Shaft Fractures Treated with Compression Plate Fixation in Adults: A Systematic Review on Adverse Events and Outcomes.

Both-bone forearm shaft fractures (BBFFs) in adults carry a significant risk of adverse events (AEs). Based on the current literature, there is considerable variance in AE incidence reporting. We aimed to systematically review the literature on BBFFs in adults treated with compression plate fixation, assessing AEs and long-term outcomes. We performed a systematic review based on the PubMed database on the current literature on adult BBFFs treated with open reduction and internal fixation with compression plates. Two authors independently collected the data, and a third author resolved disagreements between the 2 reviewers. The primary outcome measure was postoperative AEs, whereas the secondary outcome was to review the long-term outcomes. We evaluated the methodological quality of the studies with a modified version of the Coleman Methodology Score. Fifteen studies (12 retrospective case series and 3 randomized controlled trials) met the set inclusion criteria. In total, there were 944 patients, of whom 24% (n = 224) experienced some AEs, and 14% had major AEs requiring secondary operations or remaining persistent. The most common AEs were postoperative nerve injuries (incidence 7%, n = 64/944) and fracture nonunion (incidence 5%, n = 45/944). Disabilities of the Arm, Shoulder, and Hand scores were available for 135 patients (5 studies), with a mean score of 12.5 (range 0-61). According to the modified Coleman Methodology Scores, there were 2 good-, 1 fair-, and 12 poor-quality studies among the included studies. BBFF compression plate fixation in adults poses a relatively high AE risk (24%). According to available patient-reported outcomes and range of motion measurements, the average postoperative outcomes are good, although a minor disability typically persists to some extent. There is a need for high-quality prospective trials assessing the treatment and outcomes of BBFFs in adults to improve forearm fracture treatment. Level III. See Instructions for Authors for a complete description of levels of evidence.

The Seasonality of Childhood Bone and Joint Infection with Focus on Kingella kingae

Background: Seasonal trends in hospitalization for childhood bone and joint infection (BJI) are reported inconsistently. True seasonal variation would suggest an element of disease risk from environmental factors. This review evaluates all reported seasonal variations in childhood BJI, with additional analysis of seasonal trends for diseases secondary to Kingella kingae. Methods: A systematic review of the literature was undertaken from January 1, 1980, to August 1, 2024. Data were extracted on the hospitalization rate by season and/or month. Pathogen-specific studies for BJI secondary to K. kingae were examined separately. Results: Twenty studies met inclusion criteria encompassing 35,279 cases of childhood BJI. Most studies reported seasonal variation (n = 15, 75%). Eight studies specifically considered disease secondary to K. kingae, and all reported more frequent hospitalization in autumn and/or winter. This is in keeping with the role of respiratory pathogens and seasonal viruses in disease etiology for K. kingae BJI. Findings from other studies on the seasonality of childhood BJI were inconsistent. There were reported seasonal peaks in autumn/winter (4 studies), summer/spring (5 studies), or no variation (5 studies). Where microbiologic data were available, Staphylococcus aureus was the primary pathogen. The quality assessment demonstrated confounding and heterogeneous inclusion criteria affecting the seasonal analysis. Conclusion: For childhood BJI caused by K. kingae, there appears to be a higher risk of hospitalization in autumn and/or winter months. This may relate to the seasonal circulation of respiratory viruses. There is currently insufficient evidence to support other forms of seasonal variation. Reported findings are likely affected by regional disease and pathogen characteristics. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Recovery of Comfort and Capability After Upper Extremity Fracture Is Predominantly Associated With Mindset: A Longitudinal Cohort From the United Kingdom

OBJECTIVES: To determine the relative influence of mindset and fracture severity on 9-month recovery trajectories of pain and capability after upper extremity fractures. METHODS: Design: Secondary use of longitudinal data. Setting: Single Level-1 trauma center in Oxford, United Kingdom. Patient selection: English-speaking adults with isolated proximal humerus, elbow, or distal radius fracture managed operatively or nonoperatively were included, and those with multiple fractures or cognitive deficit were excluded. Outcome measures and comparisons: Incapability (Quick-DASH) and pain intensity (11-point rating scale) were measured at baseline, 2–4 weeks, and 6–9 months after injury. Cluster analysis was used to identify statistical groupings of mindset (PROMIS Depression and Anxiety, Pain Catastrophizing Scale, and Tampa Scale for Kinesiophobia) and fracture severity (low/moderate/high based on OTA/AO classification). The recovery trajectories of incapability and pain intensity for each mindset grouping were assessed, accounting for various fracture-related aspects. RESULTS: Among 703 included patients (age 59 ± 21 years, 66% women, 16% high-energy injury), 4 statistical groupings with escalating levels of distress and unhelpful thoughts were identified (fracture severity was omitted considering it had no differentiating effect). Groups with less healthy mindset had a worse baseline incapability (group 2: β = 4.1, 3: β = 7.5, and 4: β = 17) and pain intensity (group 3: β = 0.70 and 4: β = 1.4) (P &lt; 0.01). Higher fracture severity (β = 4.5), high-energy injury (β = 4.0), and nerve palsy (β = 8.1) were associated with worse baseline incapability (P &lt; 0.01), and high-energy injury (β = 0.62) and nerve palsy (β = 0.76) with worse baseline pain intensity (P &lt; 0.01). Groups 3 and 4 had a prolonged rate of recovery of incapability (β = 1.3, β = 7.0) and pain intensity (β = 0.19, β = 1.1) (P &lt; 0.02). CONCLUSIONS: Patients with higher levels of unhelpful thinking and feelings of distress regarding symptoms experienced worse recovery of pain and incapability, with a higher effect size than fracture location, fracture severity, high-energy injury, and nerve palsy. These findings underline the importance of anticipating and addressing mental health concerns during recovery from injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Lower Extremity Trauma is Associated with an Increased Rate of New Mental Disorder Diagnosis and Suicide Attempt.

To evaluate the risk of developing a new mental disorder diagnosis within two years of lower extremity fracture. Design: Retrospective cohort study. National insurance claims database. Included were patients between the ages of 18 and 65 with lower extremity, pelvis and acetabular fractures without prior mental disorders as defined with ICD-9 and ICD-10 diagnosis codes. Mental disorders evaluated included alcohol use disorder, generalized anxiety disorder, bipolar disorder, major depressive disorder, drug use disorder, panic disorder, post-traumatic stress disorder, and suicide attempt.Outcome Measures and Comparisons: The individual lower extremity fracture cohorts were matched 1:4 with non-fracture controls. The specific groups of interest were pelvis fractures, acetabulum fractures, proximal femur fractures, femoral shaft fractures, distal femur fractures, patella fractures, tibia plateau fractures, tibia shaft fractures, ankle fractures, pilon fractures, calcaneus fractures, and Lisfranc fractures. Rates of mental disorders after primary lower extremity fractures within two years were compared using multivariable logistic regression. Overall, the 263,988 patient fracture group was 57.2% female with an average age of 46.6 years. Compared to controls with no fracture, patients who sustained pelvis, acetabulum, proximal femur, femoral shaft, distal femur, patella, tibia plateau, tibia shaft, pilon, calcaneus, or Lisfranc fracture had a statistically significant increased risk of being diagnosed with a queried mental disorder within two years of fracture. When comparing all fracture patients by location, those suffering from fractures proximal to the knee joint, including pelvis fractures (OR: 1.51, 95% CI: 1.39-1.64) and proximal femur fractures (OR: 1.36, 95% CI: 1.26-1.47), demonstrated greater risk of developing any of the queried mental disorders compared fractures distal to the knee, including ankle fractures (OR: 0.99, 95% CI: 0.95-1.03) and pilon fractures (OR: 1.05, 95% CI: 0.81-1.36). When comparing specific fracture patients to patients without fracture by mental disorder, patients demonstrated an increased risk of suicide attempt following fracture of the pelvis, acetabulum, femoral shaft, distal femur, and calcaneus, as well as patients suffering a Lisfranc fracture. There is an increased risk of being diagnosed with a new mental disorder following lower extremity trauma in patients without prior mental disorder diagnosis compared to matched individuals without a lower extremity fracture. Among the fractures studied, those that were more proximal, such as pelvis and proximal femur fractures, carried the greatest risk compared to more distal fracture sites, including ankle and pilon fractures. Patients who experienced certain lower extremity fractures had a significantly higher rate of suicide attempt compared to patients without fracture. Physicians should consider increased mental health screening and potential referral for mental health evaluation for patients following lower extremity trauma. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Effect of a Flipped Classroom Didactic Curriculum on Orthopaedic In-Training Examination Scores for a Resident Cohort.

There is little research on the efficacy of flipped classroom (FC) models of learning in formal orthopaedic didactic curricula. The primary aim of this study was to compare resident Orthopaedic In-Training Examination (OITE) scores before and after implementation of an FC curriculum at a single academic institution. An FC didactic model consisting of 3 hour-long weekly sessions focusing on highly tested topics was implemented for the start of the 2021 to 2022 academic year. The curriculum was based on the Orthobullets PASS curriculum. The OITE scores were measured 3 years before and 3 years after the implementation of the novel curriculum. Mean in-training scores as a program against national peers increased from the 29th percentile precurriculum implementation to 75th percentile postcurriculum implementation (p < 0.001). At a single academic institution, average OITE scores increased significantly after implementation of an FC model. Consideration should be given to changing traditional lecture-based curricula to models that more effectively engage resident learners. Level III: Retrospective Cohort Study. See Instructions for Authors for a complete description of levels of evidence.

The Dangers of Distracted Driving: A Substudy of Patient Perception Data From the DRIVSAFE Observational Study.

To determine how fracture clinic patients perceive the dangers of distracted driving. Analysis of patient perception subset data from the original DRIVSAFE study; a large, multicenter cross-sectional study, surveying fracture clinic patients about distracted driving. Four Level 1 Canadian trauma center fracture clinics. English-speaking patients with a valid Canadian driver's license and a traumatic musculoskeletal injury sustained in the past 6 months. Primary outcome was patients' safety ratings of driving distractions. As per the original DRIVSAFE study, patients were categorized as distraction-prone or distraction-averse using their questionnaire responses and published crash-risk odds ratios (ORs). A regression analysis was performed to identify associations with unsafe driving perceptions. The study included 1378 patients, 749 (54.3%) male and 614 (44.6%) female. The average age was 45.8 ± 17.0 years (range 16-87). Sending electronic messages was perceived as unsafe by 92.9% (1242/1337) of patients, while reading them was seen as unsafe by 81.2% (1086/1337). Approximately three-quarters of patients viewed making (78.9%, 1061/1344) and accepting (74.8%, 998/1335) calls on handheld mobile phones as unsafe. However, 31.0% (421/1356) of patients believed that they had no differences in their driving ability when talking on the phone while 13.1% (175/1340) reported no driving differences when texting. Younger age (OR, 0.93 [95% confidence interval (CI) 0.90-0.96], P < 0.001), driving experience (OR, 1.06 [95% CI 1.02-1.09], P < 0.001), and distraction-prone drivers (OR, 3.79 [95% CI 2.91-4.94], P < 0.001) were associated with unsafe driving perceptions. There is a clear association between being prone to distractions and unsafe driving perceptions, with distraction-prone drivers being 3.8 times more likely to perceive driving distractions as safe. This information could potentially influence the appropriate delivery and content of future educational efforts to change the perception of driving distractions and thereby reduce distracted driving. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparative Efficacy and Safety of Intramedullary Lengthening Nails vs. Alternative Techniques for Femoral Limb Lengthening: A Systematic Review and Meta-Analysis.

Limb lengthening procedures are performed for various indications, including limb length discrepancies (LLDs) and short stature. This systematic review and meta-analysis compares the efficacy and safety of the newer motorized intramedullary lengthening nails (MILNs) with the traditional alternative techniques (ATs) for femoral limb lengthening. We conducted a comprehensive literature search in the Medline, Embase, Cochrane, Web of Science, and Scopus databases, inclusive of all dates through July 1, 2023, and without language restrictions. Factors mediating outcomes included problems, obstacles, complications, total adverse events, healing/consolidation index, time to full weight-bearing, lengthening accuracy, percentage of lengthening goal achieved, and duration of hospital stay. Effect sizes were quantified using STATA 17.0. Statistical algorithms employed were random effects model standardized mean differences (SMDs) for continuous outcomes and log risk ratios (RRs) for dichotomous outcomes, both with 95% confidence intervals (CIs). Our meta-analysis included 10 studies comparing MILN with AT: 180 femurs in the MILN group and 160 femurs in the AT group. This was exclusively comprised of retrospective cohort studies. When compared with AT, limb lengthening procedures utilizing MILNs had significantly lower problems (log RR, -1.35; 95% CI, -1.93 to -0.77; p < 0.001), complications (log RR, -0.56; 95% CI, -0.90 to -0.22; p = 0.001), and total adverse events (log RR, -0.69; 95% CI, -1.17 to -0.21; p = 0.005), as well as a superior bone healing index (SMD, -0.80; 95% CI, -1.32 to -0.28; p = 0.003). However, no significant differences were found in obstacles, percentage of lengthening goal achieved, lengthening accuracy, time to full weight-bearing, and duration of hospital stay. Limb lengthening with MILNs vs. AT may offer more favorable patient outcomes, lowering risk for problems, complications, and total adverse events, while optimizing the bone healing/consolidation index. However, the limitation of nonrandomized retrospective studies and high heterogeneity should be acknowledged. Level II (meta-analysis of cohort studies). See Instructions for Authors for a complete description of levels of evidence.

Short term road network Macroscopic Fundamental Diagram parameters and traffic state prediction based on LSTM

Macroscopic Fundamental Diagram (MFD) is widely used in traffic state evaluation due to its description of the macro level of urban road network. This study focuses on the discrimination and short-term prediction of macro traffic states in urban road networks, using MFD combined with FCM clustering for state partitioning to characterize different macro states of the road network. To predict the MFD state, this paper builds two LSTMs to perform short-term predictions on two important parameters in MFD: road network weighted flow qw and road network weighted density kw. The parameters of the first three statistical intervals and the predicted time period are used as inputs to output the MFD parameters for the predicted time period. To ensure that the two LSTM structures and hyper-parameters settings can achieve the best prediction performance for MFD, the parameter optimization process of both should be included in the same search framework for hyper-parameters search. Therefore, this paper uses GA algorithm combined with multi-objective particle swarm optimization algorithm as the solving algorithm, with the accuracy of solving two MFD parameters and the accuracy of MFD point positioning as the hyper-parameters solving objectives. The study was validated using actual road network data from Hong Kong, and the results showed that the method proposed in this paper has an MRE prediction error of less than 7.8% for the two parameters of MFD, and can predict the future temporal trend of the two parameters, demonstrating the feasibility of MFD related predictions. The model's prediction of the overall shape and change trajectory trend of MFD is consistent with reality, and some test sets in MFD state prediction show high accuracy, the overall accuracy is 81.45%. To verify the effectiveness of the multi-objective search algorithm, typical LSTM models and RNN models were used for comparison. The experiment proved that the model used in this study performed better in error control and state prediction. This study explores and practices a short-term prediction method for road network MFD parameters, MFD status, and their changing trends. Provided path reference for urban road network prediction, traffic control status, and MFD related research.

Texture Analysis and Classification using Local Binary Patterns and Statistical Features

Texture analysis and classification are crucial in many applications such as medical applications, satellite imagery analysis, and so on. This paper presents a new technique that incorporates the LBP with the HOG to improve the texture analysis and classification. LBP is famous for finding out the local texture descriptors by comparing the pixel intensities it deals with and can challenge light variations and image transformations. On the other hand, there is HOG which emphasizes edge and gradient information to detect the orientation and shape of a texture in a given image. While LBP describes the local micro-patterns HOG gives the perspective of the global gradient orientation. The combined use of local and global texture information is helpful in the presented problem when prioritizing the recognition of complex texture patterns that cannot be deciphered by a single algorithm. To demonstrate the efficiency of the proposed hybrid method, several experiments are performed on several texture databases. According to the findings, the proposed LBP-HOG strategy proves more beneficial than basic LBP and HOG techniques concerning the classification rate and computing time. The combination method shows improved performance in terms of agreement with the reference of fine and coarse level of texture descriptions along with providing large-scale description of the texture which results in the improved discriminatory power of the texture classes.

Comparing head-mounted and handheld augmented reality for guided assembly

Different Augmented Reality (AR) displays are becoming more commonly used for work since AR promises benefits by offering support, e.g., with additional information or hints. However, most research compares AR with traditional work support, like paper-based or web-based instructions. Since various AR technologies offer device-specific advantages and disadvantages, different AR technologies are more or less suitable to offer support without overwhelming or distracting the worker. Research, therefore, needs to derive empirical results from comparing different AR displays to derive concrete recommendations for action on the use and design of AR for specific contexts. To address this research gap, this experimental study investigates the effect of video-see-through head-mounted AR (Varjo XR-3) vs. handheld AR (Apple iPad) on performance (time and committed failure), motivation, and cognitive load for guided assembly. The study results reveal that both AR displays can successfully guide people in guided assembly tasks. On a descriptive level, the head-mounted AR device reveals slightly better results in terms of time and committed failures. Notably, the impact of technical restrictions on the study results was still evident. Accordingly, further investigation of device-specific differences is of continuing importance.

The Description of the Severity Level of Dental Caries in Visually Impaired Students at The Special School (SLB) Semarang

The Description of the Severity Level of Dental Caries in Visually Impaired Students at The Special School (SLB) Semarang