Description Of Levels Research Articles

Inability to Remove Locking Screws From the Femoral Neck System Due to Stripping of the Screwdriver Within the Locking Screw Head.

The purposes of this study were to investigate the frequency of screwdriver stripping in the head of the locking screw that attaches to the side plate to the femur shaft among the patients who underwent implant removal after femoral neck system (FNS) for femoral neck fracture, to determine the risk factors for locking head screw stripping in FNS treatment of femoral neck fracture, and to suggest a surgical tip that removes FNS, which is difficult to remove due to screw stripping. Retrospective cohort study. Eight Urban tertiary referral academic hospitals. Included were patients with Orthopedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen 31-B1, 31-B2, and 31-B3 femoral neck fractures who underwent surgical fixation with FNS from November 2019 to February 2023. The frequency of locking head screw stripping of FNS during the implant removal was evaluated. Among the 47 patients (18 (38%) men and 29 (62%) women) who met the inclusion criteria with an average age of 59.2 years (range, 28-94 years), 13 (27.7%) experienced screwdriver stripping in the head of the distal locking screw during FNS removal surgery. A higher body mass index showed a borderline significant association with the stripping in the adjusted model (odds ratio = 1.233; 95% confidence interval: 0.988-1.539; P = 0.064). No other variables showed significant association with the stripped locking head screw ( P > 0.05). Stripping of the screwdriver within the head of the distal locking screw occurred in over one-quarter of cases. While a higher body mass index demonstrated a borderline significant association, none of the other variables examined showed a statistically significant relationship with the stripped locking head screw. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

An Updated Demographic Profile of Orthopaedic Surgery Using a New ABOS Data Set.

The orthopaedic surgery physician workforce is predominately White and male and has been identified as the least diverse medical specialty. Increasing efforts toward diversification within orthopaedic surgery are underway. Evaluating the effectiveness of these programs requires a thorough understanding of the current demographic profile of the profession. The American Board of Orthopaedic Surgery (ABOS) is the leading board certification organization for orthopaedic surgeons in the United States. The ABOS began collecting self-reported race/ethnicity and sex/gender data of its examinees and diplomates in 2017. This new data set of ABOS was analyzed to describe both the current demographic profile of orthopaedic surgery and trends over time. Underrepresented minority (URM) was defined as a group that is less well represented in orthopaedic surgery than in US census data and includes female, American Indian or Alaska Native, Black or African American, Hispanic/Latino, and Native Hawaiian or Other Pacific Islander categories. Of the 21,025 currently practicing ABOS diplomates with time-limited ABOS certificates (issued since 1986), 19,912 (94.7%) provided sex/gender data, and 19,876 (94.5%) provided race/ethnicity data. Approximately 84.78% selected male and 8.43% female. The majority identified as White (73.67%), whereas 16.35% selected a URM race/ethnicity category. There have been significant increases in the proportions of female (odds ratio [OR] = 4.72, 95% confidence interval [CI] = 3.64-6.11, p < 0.001) and URM (OR = 2.31, 95% CI = 1.80-2.96, p < 0.0001). Diplomates among orthopaedic surgeons attaining ABOS board Diplomates from 1989 to present. Among the subspecialties, pediatric orthopaedics reported the highest percentage of females (30.4%). Spine had both the lowest percentage of females (2.63%) and the highest percentage of URMs (8.97%). Sports had the lowest percentage of URMs at 5.63%. Orthopaedic surgery in 2023 remains largely White and male. However, there have been promising trends toward diversification of orthopaedic surgery both in terms of gender and race/ethnicity. Specialties within orthopaedics have a wide variety of demographic profiles. Level IV Retrospective Cohort Study. See Instructions for Authors for a complete description of levels of evidence.

Functional Improvements by Controlled Suture Tension in Arthroscopic Rotator Cuff Repair.

Although a certain degree of tension in bridging sutures is required for proper tendon healing following suture-bridge rotator cuff repair, excessive suture tension may be detrimental to tendon healing. This study aimed to investigate the effects of bridging suture tension on clinical outcomes and tendon healing. We hypothesized that fixed, low tension of the bridging sutures would improve the tendon healing rate and clinical outcomes compared with maximum manual tensioning. A group of 39 patients with a rotator cuff tear were treated with arthroscopic suture-bridge rotator cuff repair, in which the bridging sutures were uniformly tensioned to 20 N (group A). A separate group of 37 patients was treated with the same suture construct, but the sutures were tensioned by maximum manual pulling (mean tension, 36.1 N; group B). The visual analog scale (VAS) score for pain, active anterior elevation, external and internal rotation, and Constant score were compared between the groups preoperatively and at 1, 3, and 6 months and 1 and 2 years postoperatively. Anatomical healing was evaluated using magnetic resonance imaging (MRI) at 1 year after surgery. At 6 months postoperatively, all clinical values had improved in both groups. The Constant score (p < 0.001), VAS pain score (p < 0.001), and anterior elevation (p = 0.004) were significantly better in group A than in group B. Two years postoperatively, there was no significant difference between groups A and B in the Constant score (p = 0.847), VAS pain score (p = 0.991), and anterior elevation (p = 0.855). Group A demonstrated a significantly lower retear rate (3 of 39, 7.7%) than group B (9 of 37, 24.3%) (p = 0.0467). Double-row suture-bridge repairs with fixed, low tension led to superior clinical outcomes at 6 months and a superior tendon healing rate at 1 year compared with repairs with higher suture tension. However, the clinical outcomes did not differ significantly at 2 years between the 2 tensioning methods. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tibial Malalignment Is an Independent Predictor of Nonunion After Intramedullary Nailing of Tibial Shaft Fractures.

This study aimed to assess the relationship between postoperative alignment and nonunion in patients with tibial shaft fractures treated with intramedullary nailing. Retrospective case-control study. Single academic trauma center. Adult patients with closed or open tibial shaft fractures (42A-C) treated with intramedullary nailing from 2007 to 2018. Case patients with nonunion were compared with control patients with radiographic evidence of healing in terms of the postoperative tibial alignment measured in the coronal and sagittal planes. Of the 192 included patients (median age, 38 years; 76% male), 51 patients had a nonunion, and 141 patients had united fractures and served as the control group. A strong association between postoperative tibial malalignment in 1 plane and nonunion (odds ratio, 3.0; 95% confidence interval, 1.1-8.3; P = 0.03) was demonstrated. This association was even greater for malalignment in both coronal and sagittal planes (odds ratio, 5.7; 95% confidence interval, 2.1-16.1; P < 0.001) after controlling for confounders. After controlling for confounding factors, postoperative malalignment in the coronal or sagittal plane was associated with significantly increased odds of tibial shaft nonunion after intramedullary nailing. Prognostic, Level III. See Instructions for Authors for a complete description of levels of evidence.

The Use of External Beam Radiation Therapy for Heterotopic Ossification Prophylaxis After Surgical Fixation of Acetabular Fractures: A Randomized Controlled Trial.

To determine the effect of external beam radiation (XRT) on preventing severe heterotopic ossification (HO) after acetabular surgery. Randomized controlled trial. Two level I academic trauma centers. Patients with an acetabular fracture (OTA/AO type 62) surgically treated through a posterior or combined anterior and posterior approach. Radiographic HO was determined using Brooker Classification at the last follow-up. The primary outcome was severe HO (Brooker classes III-IV). The secondary outcome was any HO (Brooker classes I-IV). The incidence of radiographic HO was compared between patients who did and did not undergo postoperative XRT. The results were analyzed in both an intention-to-treat (randomized to XRT) and as-treated (received XRT) basis. Severe HO occurred in 3 of 54 (6%) patients randomized to XRT and 9 of 50 (18%) patients randomized to no XRT (odds ratio 0.24, 95% confidence interval, 0.05 to 0.94; P = 0.05). Any HO occurred in 10 (19%) patients assigned to XRT and 17 (34%) patients in the no XRT control group (odds ratio 0.39; 95% confidence interval, 0.13 to 1.05; P = 0.07). The findings of this dual-center randomized controlled trial suggest that XRT after acetabular surgery significantly reduced the odds of severe HO compared with patients who did not receive XRT. These results can help guide shared decision making between surgeons and patients regarding the use of XRT for HO prophylaxis. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Hardware Removal After Lisfranc Open Reduction and Internal Fixation Results in Improved Physical Function.

The purpose of this study was to investigate whether hardware removal (HWR) after Lisfranc open reduction and internal fixation (ORIF) resulted in significant impact through PROMIS physical function (PF) and pain intensity (PI) scores. Retrospective cohort. Level-1 trauma center. Adult patients with isolated Lisfranc injuries who were treated through ORIF between 2002 and 2023 who had PROMIS PF and PI scores through 6 months follow-up were included. Patients were excluded if they received index treatment other than ORIF or underwent secondary surgical intervention before HWR. A subanalysis was performed at 1-year follow-up. Primary outcomes were PROMIS PF and PI scores. The Wilcoxon signed-rank test compared differences between PROMIS scores within the HWR group. The Wilcoxon ranked-sum test compared differences between HWR versus no HWR. Distributive MCID was calculated using the 0.5 SD method. There were 482 patients (489 feet) identified with isolated Lisfranc injuries. Seventy-seven feet underwent ORIF followed by HWR. Thirty feet underwent ORIF without HWR. The average age of the no HWR group was 45.8 (18.0-81.3) years versus the HWR group that was 38.7 (18.3-74.1) years ( P = 0.053). Nineteen (63.3%) were women in the no HWR group compared with 33 (42.9%) in the HWR group ( P = 0.084). HWR occurred an average of 4.43 months after ORIF. Patients who underwent HWR had a statistically significant increase in average PF scores (39.7-45.9, P < 0.001) at their standard 6 weeks (1.5 months) postoperative visit. HWR patients had a nonsignificant decrease in average PI scores (56.5-53.9, P = 0.24). Compared with those with retained hardware, the HWR group demonstrated a statistically significant net improvement in PF and PI scores from surgery, with an average improvement of 5.6 and 1.7, respectively ( P = 0.002, 0.008). Patients experienced significant improvement in PROMIS PF scores for Lisfranc ORIF at 6 weeks after HWR. Compared with patients with retained hardware, they also experienced significant improvement in PROMIS PF and PI scores. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

ASA Class Is a Stronger Predictor of Early Revision Risk Following Primary Total Knee Arthroplasty than BMI.

Although there is a known correlation between obesity and revision risk following total knee arthroplasty (TKA), there is an ongoing debate regarding the appropriateness of denying TKA solely based on the body mass index (BMI) of a patient. Our aim was to determine whether a patient's American Society of Anesthesiologists (ASA) class predicts their risks of early all-cause revision and revision for periprosthetic joint infection (PJI) following primary TKA, independent of their BMI. Data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) were obtained regarding all patients who underwent primary TKA for osteoarthritis in Australia from January 1, 2015, to December 31, 2022. Estimated hazard ratios of all-cause revision and revision for PJI, as well as predicted risks of revision within 3 months, 1 year, and 2 years, as a function of patient ASA class and BMI, were calculated with use of multivariable Cox proportional hazards models. A total of 274,786 primary TKAs (54.5% female; mean age, 68.3 years) were included in the study, of which 5,401 were revised during the study period. Compared with BMI, ASA class was a stronger predictor of the risks of all-cause revision and revision for PJI following primary TKA. Patients with an ASA class of 3 to 4 had higher risks of all-cause revision and revision for PJI at multiple time points after TKA compared with patients with an ASA class of 1 to 2, regardless of BMI. Although ASA class and BMI are theoretically interrelated variables, we found that a patient's ASA class was more strongly associated with their risks of early all-cause revision and revision for PJI following primary TKA than their BMI. Employing a BMI threshold in isolation when assessing fitness for TKA may be inappropriate, and surgeons should give greater weight to the other medical comorbidities and general perioperative fitness of the patient. Patients with poorly controlled comorbidities should be referred for medical optimization prior to TKA. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Consolidation of the Anteromedial Aspect of the Tibia Is Inferior to the Other Areas in the Reconstruction of Critical-Sized Bone Defect of the Tibial Shaft Using the Induced Membrane Technique: An Analysis of 111 Serial Computed Tomography of 37 Patients.

To compare the consolidation quality between the anteromedial aspect of regenerated bone (AMRB) and the other areas of regenerated bone (TORB) following the induced membrane technique (IMT) for managing critical-sized tibial shaft bone defects, and determine the factors affecting consolidation quality in the AMRB. Retrospective comparative study. Academic Level I trauma center. Included were patients who underwent IMT with only an intramedullary nail for tibial shaft segmental defects and serial computed tomography immediately, 6 months, and 1 year postoperatively. Comparison were made of regenerative bone volume, density, and corticalization between AMRB and TORB. This study enrolled 37 patients with a mean age of 47.7 years (range 20-79). Twenty-eight (75.7%) patients were men. Postoperatively, the AMRB exhibited significantly more negative volumetric change than TORB at 0-1 year (-20.01% ± 25.59% vs. -13.32% ± 22.48%, P = 0.028), less positive density change 0-6 months (+197.84 ± 107.95 vs. +290.14 ± 131.74 Hounsfield unit (HU), P < 0.001) and 0-1 year (+377.51 ± 150.71 HU vs. +455.48 ± 135.04 HU, P < 0.001), and lower corticalization rate in 1 year (49.77% ± 29.42% vs. 82.27 ± 19.73%, P < 0.001). Significant factors included fracture-related infection (FRI) ( P = 0.047 and P = 0.048 at 0-6 months and 0-1 year, respectively) and longer defect length ( P = 0.032 and P = 0.020) for the negative volumetric AMRB changes; older age ( P = 0.004 and P = 0.016) for the AMRB negative density changes; higher percentage of mixed recombinant human bone morphogenetic protein-2 in graft material ( P = 0.013 in 0-6 months) for the AMRB positive density change; FRI ( P = 0.024) for the inferior corticalization rate of the AMRB; FRI ( P = 0.026 in 0-1 year), longer defect length ( P = 0.017 in 0-6 months), and higher mixed demineralized bone matrix percentage ( P = 0.010 in 0-1 year) for the difference in density change between the AMRB and TORB; higher mixed demineralized bone matrix percentage ( P = 0.023) for the difference between the AMRB and TORB in corticalization rates. The tibial shaft's anteromedial aspects demonstrated significantly inferior consolidation after IMT, especially in terms of volume at 6 months, density at 6 months and 1 year, and corticalization at 1 year postoperatively. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cast-OFF 2: One Week Versus 3-5 Weeks of Plaster Cast Immobilization for Non- or Minimally Displaced Distal Radius Fractures-A Stepped Wedge Cluster Randomized Controlled Trial.

Implementation of 1 week of cast immobilization followed by gradually increasing wrist mobilization for non- or minimally displaced distal radius fracture (DRF) and comparison of the functional outcomes and pain scores with the usual care (3-5 weeks of cast immobilization). A randomized stepped wedge cluster design, prospective cohort. Academic and peripheral hospitals in levels 1, 2, and 3 trauma centers. All patients between 18 and 85 years old with an isolated non- or minimally and nonreduced DRF were eligible for inclusion. Participating hospitals were randomized to transition from usual care (3-5 weeks of cast immobilization) to 1 week of cast immobilization, following the stepped wedge design. Patient characteristics, secondary dislocation, surgical treatment, visual analog scale, Patient Rated Wrist Evaluation (PRWE), Patient Reported Outcomes Measurement Information System Pain Interference, Pain Catastrophizing Scale 4, and patient satisfaction were compared between control and intervention group at weeks 1, 3-5, 6, months 3, 6, and 12. A difference around 11 points on the PRWE scale was considered clinically significant. Four hundred two patients were included (control n = 197 vs. intervention n = 205, 267/135, female/male). There were no differences in age (53.7 ± 18.6 vs. 53.3 ± 19.5, P = 0.27), sex (66% vs. 67% female, P = 0.44), dominant hand fractured (44% vs. 53%, P = 0.39), and type of fracture (39% vs. 41% extra-articular, P = 0.44). After 6 weeks, the PRWE score showed no clinically significant differences (-4.5 [confidence interval -12.9 to 4.02], P = 0.30). No significant differences were observed for function, pain scores, and patient satisfaction between groups (all P > 0.05). Furthermore, there was no significant difference in secondary dislocation rate (control 1.5% vs. intervention 1.0%, P = 0.32) and operation rate (control 1.5% vs. 1.5% intervention, P = 0.92). This study compared 1 week of cast immobilization followed by gradually increasing wrist mobilization to the usual care of 3-5 weeks for nonreduced DRF. No clinically significant differences in function, pain scores, patient satisfaction, secondary dislocation, and operations were observed. Therefore, 1 week of plaster immobilization can be safely recommended for the non- or minimally displaced and nonreduced DRF treatment. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Evolution of Sagittal Spinal Alignment During Pubertal Growth: A Large-Scale Study in a Chinese Pediatric Population.

Previous studies have reported normative data for sagittal spinal alignment in asymptomatic adults. The sagittal spinal alignment change in European children was recently reported. However, there is a lack of studies on the normative reference values of sagittal spinal and pelvic alignment and how these parameters change at different growth stages in Chinese children. The aims of this study were to establish the normative reference values of sagittal spinopelvic parameters in Chinese children, to investigate their variation during growth, and to compare these parameters between Chinese and European populations. The radiographic data of 1,916 healthy Chinese children (female:male sex ratio, 1.02:1; mean age, 11.9 ± 4.3 years) were analyzed in a retrospective, single-center study. Full-spine radiographs were utilized to measure several sagittal parameters, including pelvic parameters, T1-T12 thoracic kyphosis (TK), and L1-S1 lumbar lordosis (LL). TK was divided into proximal, middle, and distal parts, and LL was divided into proximal and distal parts. Patients were stratified into 5 groups according to skeletal maturity (based on age, Risser sign, and triradiate cartilage status). During skeletal growth, pelvic incidence (PI) increased from 31.3° to 38.4° (p < 0.001), and pelvic tilt (PT) increased from 7.8° to 12.2° (p < 0.001). There were also increases in LL (from 45.0° to 46.3°; p = 0.020) and proximal LL (from 14.5° to 15.9°; p = 0.023). The peak of change in PI occurred between Groups 1 and 2 (from 31.3° to 35.8°; p = 0.011). The peak of change in LL was observed between Groups 1 and 3 (from 45.0° to 47.7°; p = 0.008). The peak of change in proximal LL (from 14.5° to 15.9°; p = 0.039) and distal TK (from 6.1° to 6.9°; p = 0.039) occurred between Groups 1 and 5. A subgroup comparison showed that age and TK were significantly higher in male patients than in female patients across the skeletal growth groups. This was a comprehensive study of sagittal alignment in a large cohort of Chinese children. These findings can serve as age, sex, and ethnicity-specific reference values for spine surgeons when assessing and planning correction surgery for pediatric patients. The sagittal alignment variations during skeletal growth were different from those in European children, representing a unique cascade effect occurring during skeletal maturation in the Chinese population. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Risk of Postoperative Periprosthetic Femoral Fracture After Total Hip Arthroplasty Depends More on Stem Design Than Cement Use: An Analysis of National Health Data from England.

In this study, we estimated the risk of surgically treated postoperative periprosthetic femoral fractures (POPFFs) associated with femoral implants frequently used for total hip arthroplasty (THA). In this cohort study of patients who underwent primary THA in England between January 1, 2004, and December 31, 2020, POPFFs were identified from prospectively collected revision records and national hospital records. POPFF incidence rates, adjusting for potential confounders, were estimated for common stems. Subgroup analyses were performed for patients >70 years of age, with non-osteoarthritic indications, and with femoral neck fracture. POPFFs occurred in 0.6% (5,100) of 809,832 cases during a median follow-up of 6.5 years (interquartile range [IQR], 3.9 to 9.6 years). After cemented stem implantation, the majority of POPFFs were treated with fixation. Adjusted prosthesis time incidence rates (PTIRs) for POPFFs varied by stem design, regardless of cement fixation. Cemented composite beam (CB) stems demonstrated the lowest risk of POPFF. Collared cementless stems had an equivalent or lower rate of POPFF compared with the current gold standard of a polished taper slip cemented stem. Cemented CB stems were associated with the lowest POPFF risk, and some cementless stem designs outperformed modern cemented stem designs. Stem design was strongly associated with POPFF risk, regardless of the presence of cement. Surgeons, policymakers, and patients should consider these findings when considering femoral implants in those most at risk for POPFF. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Descriptive analysis of professional competences

The present work focused on an intervention program based on professional skills to promote employability. Emotional competencies were analyzed, as the delimitation of interpersonal competencies, the factors influencing teacher employability, and professional competencies. The methodology applied was cross-sectional, descriptive, and correlational, aimed at describing, explaining, and identifying the degree of correspondence of the possible relationships between the variables. The approach was qualitative, while the method used was hypothetical-deductive, the type of research was basic, and the design was non-experimental at a correlational descriptive level with cross-sectional. The main results showed a relationship between professional competencies, employability, and the work context.

Outcomes of Calcaneal Lengthening Osteotomy in Ambulatory Patients with Cerebral Palsy and Planovalgus Foot Deformity.

To date, no studies have evaluated the longevity of calcaneal lengthening osteotomy (CLO) in patients with cerebral palsy (CP) and pes planovalgus. This study aimed to explore the changes in foot alignment following CLO in patients with CP, utilizing both radiographic evaluations and dynamic foot-pressure assessments. A retrospective study of 282 feet in 180 ambulatory patients was performed. The mean patient age at the surgical procedure was 8.9 ± 2.6 years. The mean follow-up period was 8.0 ± 4.3 years, and the mean age at the final follow-up 16.9 ± 4.4 years. Weight-bearing radiographs at 3 separate time points (before the surgical procedure, 6 months postoperatively, and at the final follow-up) were used. The feet were classified as corrected, undercorrected, or overcorrected on the basis of the radiographic parameters. At the final follow-up, we classified 98 feet (34.8%) as corrected, 58 (20.6%) as undercorrected, and 126 (44.7%) as overcorrected. Foot-pressure analysis demonstrated that the undercorrected feet had higher relative vertical impulses in the medial forefoot and medial midfoot than in the other groups, whereas the overcorrected feet had higher impulse in the lateral midfoot. There were no significant differences in preoperative radiographic parameters between the 3 groups, except for the calcaneal pitch angle. At 6 months after the surgical procedure, we classified 181 feet (64.2%) as corrected, 58 (20.6%) as undercorrected, and 43 (15.2%) as overcorrected. However, 53.6% of initially corrected feet changed to being undercorrected or overcorrected during further follow-up, 43.1% of the undercorrected feet became corrected or overcorrected, and 16.3% of the overcorrected feet became corrected. A younger age at the surgical procedure and lower naviculocuboid overlap at 6 months after the surgical procedure were the risk factors for overcorrection. Although CLO is an effective method for correcting planovalgus foot deformities and enhancing foot-pressure distribution, the extent of correction observed early after the surgical procedure was not necessarily sustained over the follow-up period in individuals with CP. Furthermore, our findings highlight a noticeable tendency toward the overcorrection of the deformity, as evidenced by increased pressure exerted on the lateral midfoot. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Delayed Surgery Increases the Rate of Infection in Closed Diaphyseal Tibial and Femoral Fractures.

Although delays in musculoskeletal care in low- and middle-income countries (LMICs) are well documented in the open fracture literature, the impact of surgical delays on closed fractures is not well understood. This study aimed to assess the impact of surgical delay on the risk of infection in closed long-bone fractures treated with intramedullary nailing in LMICs. Using the SIGN (Surgical Implant Generation Network) Surgical Database, patients ≥16 years of age who were treated with intramedullary nailing for closed diaphyseal femoral and tibial fractures from January 2018 to December 2021 were identified. Infection was diagnosed based on the assessment by the treating surgeon. A logistic regression model, adjusting for potential confounders, was used to analyze the association between delays to surgery (in weeks) and infection. Of the 9,477 closed fractures that were included in this study, 58% were femoral fractures and 42% were tibial fractures. The mean age was 35 years, and 76.2% of the patients were men. The mean delay to surgery was 10.5 days, and the median delay to surgery was 6 days. The overall infection rate was 3.1%. The odds of developing an infection increased by 9.2% with each week of delayed surgical treatment (odds ratio,1.092; 95% confidence interval, 1.042 to 1.145). Increasing delays were also associated with longer surgery duration and higher rates of open reduction. Surgical delays in LMICs were associated with an increased risk of infection in closed long-bone fractures. This study quantified the increased risk of infection due to delays in receiving care, highlighting the importance of timely surgery for closed fractures in LMICs. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Modeling impairment of ionic regulation with extended Adaptive Exponential integrate-and-fire models.

To model the dynamics of neuron membrane excitability many models can be considered, from the most biophysically detailed to the highest level of phenomenological description. Recent works at the single neuron level have shown the importance of taking into account the evolution of slow variables such as ionic concentration. A reduction of such a model to models of the integrate-and-fire family is interesting to then go to large network models. In this paper, we introduce a way to consider the impairment of ionic regulation by adding a third, slow, variable to the adaptive Exponential integrate-and-fire model (AdEx). We then implement and simulate a network including this model. We find that this network was able to generate normal and epileptic discharges. This model should be useful for the design of network simulations of normal and pathological states.

Common Comorbidities and a Comparison of 4 Comorbidity Indices in Patients Undergoing Orthopaedic Oncology Surgery.

Comorbidity indices are used to help to estimate patients' length of hospital stay, care costs, outcomes, and mortality. Increasingly, they are considered in reimbursement models. The applicability of comorbidity indices to patients undergoing orthopaedic oncology surgery has not been studied. The purpose of this study was to determine the predominant comorbidities in patients undergoing orthopaedic oncology surgery and to evaluate the predictive value of these indices. Patient demographic characteristics, diagnoses, and preoperative comorbidities were collected retrospectively on 300 patients undergoing orthopaedic oncology surgery between January 2014 and March 2023. In this study, 3 subsets of 100 patients each with malignant primary bone tumors, malignant primary soft-tissue tumors, or osseous metastatic disease were randomly selected. Comorbidities were tabulated and weighted according to the guidelines of the Charlson Comorbidity Index (CCI), the National Institute on Aging/National Cancer Institute (NIA/NCI) index, the van Walraven Index, and the Agency for Healthcare Research and Quality (AHRQ) Index. Two-tailed bivariate Pearson correlations were performed to assess the relationship between the indices and between each index and patient outcomes. Comorbidities in our patient population were compared with those published in other studies. The predominant comorbidities in patients undergoing orthopaedic oncology surgery were hypertension, deficiency anemias, metastatic disease, recent unintended weight loss or being underweight, and fluid or electrolyte disorders. The percentage of patients with certain comorbidities exceeded those reported in other cancer, orthopaedic, and inpatient populations. The 4 comorbidity indices had variable correlation when assessing our patient population. The number of comorbidities and the weighted scores from all indices demonstrated little to no correlation with length of stay and survival in our patient sample. The prevalence of many comorbidities in patients undergoing orthopaedic oncology surgery is greater than those reported in other patient populations. Commonly utilized indices demonstrate variable correlation with one another. With these tools, there was little to no correlation between comorbidities and patient outcomes in our patient population. The comorbidities deemed protective in these tools may underestimate the true assessment of the comorbidities in patients undergoing orthopaedic oncology surgery. This highlights the importance of developing tools to properly assess the comorbidities in defined patient populations, especially as these models are used to set benchmarks for measuring patient outcomes; assessing quality, efficiency, and safety; and determining reimbursement criteria. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intraoperative Tranexamic Acid Infusion Reduces Perioperative Blood Loss in Pediatric Limb-Salvage Surgeries: A Double-Blinded Randomized Placebo-Controlled Trial.

Limb-salvage surgery for malignant bone tumors can be associated with considerable perioperative blood loss. The aim of this randomized controlled trial was to assess the safety and efficacy of the intraoperative infusion of tranexamic acid (TXA) in children and adolescents undergoing limb-salvage surgery. All participants were <18 years of age at the time of surgery and diagnosed with a malignant bone tumor of the femur that was treated with resection and reconstruction with a megaprosthesis. Exclusion criteria included anatomic locations other than the femur, reconstruction with a vascularized fibular graft, and a previous history of deep venous thrombosis, coagulopathy, or renal dysfunction. Participants were randomly allocated to either the TXA group (a preoperative loading dose infusion of 10 mg/kg of TXA followed by a continuous infusion of 5 mg/kg/hr until the end of surgery) or the placebo group (the same dosage but with TXA substituted with an infusion of normal saline solution). Intraoperative and perioperative blood loss were calculated with use of the hemoglobin balance method. Perioperative blood loss at postoperative day 1 and at discharge from the hospital were calculated. The total volumes of blood transfused intraoperatively and postoperatively were recorded. A statistical comparison between the groups was performed for blood loss and blood transfusion as well as for possible independent variables other than TXA, including age, body mass index, histopathologic diagnosis, tumor volume, preoperative hemoglobin level, type of resection, and the duration of surgery. A total of 48 participants, with a mean age of 12.5 ± 3.44 years (range, 5 to 18 years) and a male-to-female ratio of 1.18, were included. All participants were Egyptians by race and ethnicity. There were no minor or major drug-related adverse events. There was no significant difference between the groups with respect to intraoperative blood loss (p = 0.0616) or transfusion requirements (p = 0.812), but there was a significant difference in perioperative blood loss at postoperative day 1 (p = 0.0144) and at discharge from the hospital (p = 0.0106) and in perioperative blood transfusion (p = 0.023). TXA can be safely infused intraoperatively in children and adolescents undergoing limb-salvage surgery, and it contributes significantly to the reduction of perioperative blood loss and transfusion requirements. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Aspirin Is as Effective and Safe as Oral Anticoagulants for Venous Thromboembolism Prophylaxis After Joint Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Clinical Trials.

Joint arthroplasty effectively treats osteoarthritis, providing pain relief and improving function, but postoperative venous thromboembolism (VTE) remains a common complication. This study therefore assessed the effectiveness and safety of aspirin compared with oral anticoagulants (OACs) for VTE prophylaxis after joint arthroplasty. A systematic review and meta-analysis was performed by searching PubMed, Embase, the Web of Science, and the Cochrane Library for randomized controlled trials (RCTs) up to May 14, 2024, that compared the effect of aspirin versus OACs on VTE prophylaxis in adults undergoing joint arthroplasty. Data extraction followed the PRISMA guidelines. Two independent researchers conducted the literature searches and data extraction. A random-effects model was used to estimate effects. The primary outcome was the incidence of VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE); secondary outcomes included bleeding, wound complications, and mortality. The meta-analysis included 11 RCTs with a total of 4,717 participants (55.1% female) from several continents. The relative risk (RR) of VTE following joint arthroplasty was 1.11 (95% confidence interval [CI], 0.93 to 1.32) for aspirin compared with OACs. Similar results were observed for DVT (RR, 1.12; 95% CI, 0.90 to 1.40) and PE (RR, 1.18; 95% CI, 0.51 to 2.71). There were no significant differences in the risks of bleeding, wound complications, or mortality between patients receiving aspirin and those receiving OACs. Subgroup analyses considering factors such as study region, type of joint surgery, type of VTE detection, year of publication, use of mechanical VTE prophylaxis, aspirin dose, type of OAC comparator, study quality, and funding also found no significant differences in VTE incidence between aspirin and OACs. The overall quality of evidence for VTE and DVT outcomes was high. Based on high-quality evidence from RCTs, aspirin is as effective and safe as OACs in preventing VTE, including DVT and PE, after joint arthroplasty, without increasing complications. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Multidimensional Approach for Predicting 30-Day Mortality in Patients with a Hip Fracture: Development and External Validation of the Rotterdam Hip Fracture Mortality Prediction-30 Days (RHMP-30).

The aim of this study was to develop an accurate and clinically relevant prediction model for 30-day mortality following hip fracture surgery. A previous study protocol was utilized as a guideline for data collection and as the standard for the hip fracture treatment. Two prospective, detailed hip fracture databases of 2 different hospitals (hospital A, training cohort; hospital B, testing cohort) were utilized to obtain data. On the basis of the literature, the results of a univariable analysis, and expert opinion, 26 candidate predictors of 30-day mortality were selected. Subsequently, the training of the model, including variable selection, was performed on the training cohort (hospital A) with use of adaptive least absolute shrinkage and selection operator (LASSO) logistic regression. External validation was performed on the testing cohort (hospital B). A total of 3,523 patients were analyzed, of whom 302 (8.6%) died within 30 days after surgery. After the LASSO analysis, 7 of the 26 variables were included in the prediction model: age, gender, an American Society of Anesthesiologists score of 4, dementia, albumin level, Katz Index of Independence in Activities of Daily Living total score, and residence in a nursing home. The area under the receiver operating characteristic curve of the prediction model was 0.789 in the training cohort and 0.775 in the testing cohort. The calibration curve showed good consistency between observed and predicted 30-day mortality. The Rotterdam Hip Fracture Mortality Prediction-30 Days (RHMP-30) was developed and externally validated, and showed adequate performance in predicting 30-day mortality following hip fracture surgery. The RHMP-30 will be helpful for shared decision-making with patients regarding hip fracture treatment. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Results of 331 Two-Stage Exchanges for PJI Following THA: Low Reinfection and Mechanical Failure Rates at 10 Years.

The relative advantages and disadvantages of 2-stage versus 1-stage management of infection following total hip arthroplasty (THA) are the current subject of intense debate. To understand the merits of each approach, detailed information on the short and, importantly, longer-term outcomes of each must be known. The purpose of the present study was to assess the long-term results of 2-stage exchange arthroplasty following THA in one of the largest series to date. We identified 331 periprosthetic joint infections (PJIs) that had been treated with a 2-stage exchange arthroplasty between 1993 and 2021 at a single institution. Patients were excluded if they had had prior treatment for infection. The mean age at the time of reimplantation was 66 years, 38% of the patients were female, and the mean body mass index (BMI) was 30 kg/m2. The diagnosis of PJI was based on the 2011 Musculoskeletal Infection Society criteria. A competing-risk model accounting for death was utilized. The mean duration of follow-up was 8 years. The cumulative incidence of reinfection was 7% at 1 year and 11% at 5 and 10 years. Factors predictive of reinfection included BMI ≥30 kg/m2 (hazard ratio [HR] = 2; p = 0.049) and the need for a spacer exchange (HR = 3.2; p = 0.006). The cumulative incidence of any revision was 13% at 5 and 10 years. The cumulative incidence of aseptic revision was 3% at 1 year, 7% at 5 years, and 8% at 10 years. Dislocation occurred in 33 hips (11% at 10 years); 15 (45%) required revision. Factors predictive of dislocation were female sex (HR = 2; p = 0.047) and BMI <30 kg/m2 (HR = 3; p = 0.02). The mean Harris hip score (HHS) improved from 54 to 75 at 10 years. In this series of 331 two-stage exchange arthroplasties that were performed for the treatment of infection, we found a low rate of aseptic revision (8%) and a low rate of reinfection (11%) at 10 years. These long-term mechanical and infection data must be kept in mind when considering a paradigm shift to 1-stage exchanges. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.