Orthopaedic Literature Research Articles

Work-related musculoskeletal injuries among upper extremity surgeons: A web-based survey.

BACKGROUNDWork-related injuries have gained recent attention, especially in the orthopaedic literature. As upper extremity orthopaedic surgical tasks require repetitive and constant maneuvers, these surgeons can be at increased risk of acquiring work-related musculoskeletal (MSK) disorders during their years in practice. AIMTo assess the prevalence, characteristics and impact of MSK disorders among upper extremity orthopaedic surgeons.METHODSA modified version of the physical discomfort survey was sent to surgeons who were members of the American Shoulder and Elbow Surgeons and the Canadian shoulder and elbow society via e-mail. The collected data were analyzed using descriptive statistics, one-way analysis of variance, and Fisher's exact test. P values of < 0.05 were considered statistically significant. RESULTSOf the 142 respondents, 90.8% were males and the majority were younger than 55 years old (65.5%). A work-related MSK injury was reported by 89.4% of respondents, of which the most common diagnoses were low back pain (26.1%) and lateral elbow epicondylitis (18.3%). Among those that reported an injury, 82.7% required treatment and 26% required time off work as a direct result of their injury. The need to undergo treatment due to the injury was associated with increased number of injuries (P < 0.01). Moreover, surgeons were more likely to require time off work when they had been in practice for > 21 years (P < 0.05). CONCLUSIONA high proportion of surgeons in our survey reported MSK injuries, with more than one quarter of surgeons reported requiring time off work due to an MSK injury. The high incidence of these disorders may place a financial and psychological burden on surgeons and affect their ability to provide patient care. Awareness of operative ergonomics, irrespective of surgical specialty may help to decrease or possibly prevent the occurrence of these disorders.

Is It Cost Effective to Obtain Fungal and Acid-Fast Bacillus Cultures during Spine Debridement?

Study DesignRetrospective study.PurposeTo identify the rate of positive acid-fast bacillus (AFB) and fungal cultures during spine debridement, determine whether these infections are more common in certain spine segments, identify comorbidities associated with these infections, and determine whether the universal performance of fungal and AFB cultures during spine debridement is cost effective.Overview of LiteratureSpine infections are associated with significant morbidity and costs. Spine fungal and AFB infections are rare, but their incidence has not been well documented. As such, guidance regarding sample procurement for AFB and fungal cultures is lacking.MethodsA retrospective review of medical record data from patients undergoing spine irrigation and debridement (I&D) at the University of Missouri over a 10-year period was performed.ResultsFor patients undergoing spine I&D, there was a 4% incidence of fungal infection and 0.49% rate of AFB infection. Steroid use was associated with a higher likelihood (odds ratio, 5.62; 95% confidence interval, 1.33–23.75) of positive fungal or AFB cultures. Although not significant, patients undergoing multiple I&D procedures had higher rates of positive fungal cultures during each subsequent I&D. Over a 10-year period, if fungal cultures are obtained for each patient, it would cost our healthcare system $12,151.58. This is compared to an average cost of $177,297.64 per missed fungal infection requiring subsequent treatment.ConclusionsSpine fungal infections occur infrequently at a rate of 4%. Physicians should strongly consider obtaining samples for fungal cultures in patients undergoing spine I&D, especially those using steroids and those undergoing multiple I&Ds. Our AFB culture rates mirror the false positive rates seen in previous orthopedic literature. It is unlikely to be cost effective to send for AFB cultures in areas with low endemic rates of AFB.

The Reliability of 3-T Magnetic Resonance Imaging to Identify Arthroscopic Features of Meniscal Tears and Its Utility to Predict Meniscal Tear Reparability

Background: The ability to predict meniscus tear reparability based on preoperative magnetic resonance imaging (MRI) is desirable for postoperative planning; however, the accuracy of predictive methods varies widely within the orthopaedic and radiology literature. Purpose/Hypothesis: The purpose was to determine if the higher resolution offered by 3-T MRI improves the accuracy of predicting reparability compared with previous investigations using 1.5-T MRI. Our hypothesis was that a higher field strength of 3-T MRI would result in improved reliability assessments and predictions of meniscus tear reparability compared with previous studies utilizing a 1.5-T MRI platform. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A total of 44 patients who underwent meniscus repair were matched by age, sex, and body mass index to 43 patients who underwent partial meniscectomy. Overall, 2 orthopaedic surgeons and 2 musculoskeletal radiologists independently and blindly reviewed the preoperative MRI scans for all 87 patients. For each meniscus tear, reviewers evaluated the following criteria: tear pattern, tear length, tear distance from the meniscocapsular junction, tear thickness, and integrity of any inner meniscal fragment. The resultant data were then applied to 5 different approaches for predicting meniscal reparability. Results: The accuracy for all examined prediction methods was poor, ranging from 55% (3-point method) to 72% (classification tree method) among all reviewers. Interobserver reliability for examined criteria was also poor, with kappa values ranging from 0.07 (inner meniscal fragment status) to 0.40 (tear pattern). Conclusion: MRI continues to be a poor predictor of meniscus tear reparability as assessed by arthroscopic criteria, even when using higher resolution 3-T scanners. Interobserver reliability in this setting can be poor, even among experienced clinicians.

Failure to Achieve Threshold Scores on Patient-Reported Outcome Measures Within 1 Year Has a Predictive Risk of Subsequent Hip Surgery Within 5 Years of Primary Hip Arthroscopy: A Case-Control Study.

Background:Research has identified factors that influence achievement rates of threshold scores on patient-reported outcome measures (PROMs) after hip arthroscopy. However, little data exist on whether failure to achieve a threshold score (minimal clinically important difference [MCID] or substantial clinical benefit [SCB]) in the short term after hip arthroscopy predicts the risk of future hip surgery.Purpose/Hypothesis:The purpose of this study was to determine if failure to achieve the MCID or SCB on PROMs within 1 year of hip arthroscopy can be considered a risk factor for repeat surgery within 5 years of primary hip arthroscopy. It was hypothesized that failure to achieve threshold scores would increase the risk of subsequent hip surgery.Study Design:Case-control study; Level of evidence, 3.Methods:A retrospective review of prospectively collected data was completed. Four PROMs were collected preoperatively and within 1 year of hip arthroscopy: modified Harris Hip Score, Hip Outcome Score–Activities of Daily Living, Hip Outcome Score–Sports, and the 33-Item International Hip Outcome Tool.Results:Two cohorts were formed: (1) a study cohort (n = 88) composed of patients who underwent repeat hip surgery within 5 years of hip arthroscopy and (2) a control cohort (n = 288) composed of patients who did not require repeat hip surgery. The study cohort had significantly (P < .001) lower scores on all postoperative PROMs, and a significantly (P < .001) smaller percentage of the study cohort met the MCID and SCB. Multivariable regression analysis demonstrated that not achieving the MCID or SCB on each of the PROMs is an independent risk factor for repeat hip surgery. For every PROM in which a patient failed to achieve the MCID, the odds of subsequent surgery increased by 1.68 (95% CI, 1.42-1.98; P < .001). For every PROM in which a patient failed to achieve the SCB, the odds of subsequent surgery increased by 1.63 (95% CI, 1.35-1.97; P < .001).Conclusion:Failure to meet threshold scores on PROMs after hip arthroscopy was an independent risk factor for subsequent hip surgery. This study establishes a novel utility of PROMs and confirms the importance of these metrics in the orthopaedic literature.

Statistical Fragility of Surgical Clinical Trials in Orthopaedic Trauma

Introduction:The Fragility Index (FI) and the Fragility Quotient (FQ) are powerful statistical tools that can aid clinicians in assessing clinical trial results. The purpose of this study was to use the FI and FQ to evaluate the statistical robustness of widely cited surgical clinical trials in orthopaedic trauma.Methods:We performed a PubMed search for orthopaedic trauma clinical trials in high-impact orthopaedics-focused journals and calculated the FI and FQ for all identified dichotomous, categorical outcomes.Results:We identified 128 studies with 545 outcomes. The median FI was 5, and the median FQ was 0.0482. For statistically significant and not statistically significant outcomes, the median FIs were 3 and 5, and the mean FQs were 0.0323 and 0.0526, respectively. The FI was greater than the number of patients lost to follow-up in most outcomes.Conclusions:The orthopaedic trauma literature is of equal or higher quality than research in other orthopaedic subspecialties, suggesting that other orthopaedic subspecialties may benefit from modeling their clinical trials after those in orthopaedic trauma.

Publication Rates of Abstracts Presented at Pediatric Orthopaedic Society of North America Meetings Between 2013 and 2016.

Academic conferences such as the annual Pediatric Orthopaedic Society of North America (POSNA) meeting provide opportunities to present up-to-date scientific work that can influence clinical decision making. This study reviewed 4 years of abstracts presented at POSNA to assess trends in poster and podium presentation publication rates and associated metrics and the impact of academic presentations on the pediatric orthopaedic literature. All abstracts presented at POSNA annual meetings from 2013 to 2016 were analyzed for presentation type, subspeciality, level of evidence, study design, peer-reviewed publication within 4 years of presentation, 1-year publication rates, journal impact factors, number of authors, and citations of the final publication. χ2, analysis of variance, and t tests were conducted to measure independence of variables. Statistical significance was indicated at P<0.05. A total of 1135 abstracts were included with 676 published in peer-reviewed journals by August 2020 and 38 excluded because of publication before presentation. The number of accepted abstracts increased yearly. Total of 58.2% of POSNA abstracts were published and 42.5% had the same first author on the final manuscript. Average journal impact factor was 2.60±1.30 with a mean 14.3±16.0 citations. Podium presentations were significantly more likely to be published than poster presentations (63.1% vs. 51.2%, P<0.001) and in higher-impact factor journals. Level I evidence abstracts were published in journals with an average 1.663 higher impact factor than level V evidence abstracts, with no significant difference between overall publication rate and study type (P=0.69) or level of evidence (P=0.95) for podium presentations. The Journal of Pediatric Orthopaedics accepted the most abstracts, 38.4% overall, with 64.1% of acceptances resulting from podium presentations and no difference in time to publication based on subspecialty. The overall publication rate for POSNA abstracts has increased 8.7% from prior analysis. Podium presentations are more likely than poster presentations to be published, overall and in higher-impact journals, and are cited more frequently. Level IV-descriptive retrospective epidemiological study.

Evaluation of Low- and Middle-Income Country Authorship in the Global Orthopedics Literature

Evaluation of Low- and Middle-Income Country Authorship in the Global Orthopedics Literature

Orthopedic Surgeries: Review of Physicological Effect Pre and Post-Surgical Treatments

Patient satisfaction with a treatment is an important outcome measure and isassociated with increased adherence to that treatment. The role of psychologicalfactors with regard to successful surgical outcomes has been highlightedpreviously. This is an orthopedic literature for the psychological traits that arerelevant to surgical outcomes as well as an overview of options for psychologicallyoptimizing a patient for surgery and ways to address problems encountered inthe postoperative period in pandemic or non-pandemic before. A literature reviewwas conducted in the electronic database PubMed using keyword “Psychological”,and “Orthopedic Surgeries”. All type of studies were included for this study, suchas controlled trials, systematic reviews, literature reviews, and pilot studiespublished between 2015 and 2021. Articles which not written in English wereexcluded from the study. This search resulted in 6 papers. All of the papersdisscuss about physicological effect on pre and post-surgical treatment.Satisfaction with surgery was closely associated with physical function andanxiety before surgery. Our analysis provides low levels of evidence supportingthe use of psychological interventions, particularly with regard to anxiety andmental components of quality of life. Pre-operative anxiety, depression and lowself-efficacy are consistently associated with worse physiological surgicaloutcomes and quality of life. However, there is currently insufficient evidence tobe sure that pre-operative psychological interventions are of benefit, or whichinterventions are most effective.

Statistical Assumptions in Orthopaedic Literature: Are Study Findings at Risk?

BackgroundAs orthopaedic surgery becomes more evidence-based, the need for rigorous research has increased. This results in more complex studies that employ more sophisticated statistical analysis, often some form of regression. These statistical techniques require the data to meet certain assumptions for the findings to be considered valid. The purpose of this study is to determine the common regression techniques employed in the orthopaedic surgery literature, and demonstrate how often the assumptions of regression analyses are met and reported.MethodsStudies published in the Journal of Bone & Joint Surgery (JBJS) in 2017 and 2018 were reviewed. Commentaries, editorials, and systematic reviews were excluded. The statistical analyses performed in each study were documented. When regression analyses were utilized, the article was reviewed for evidence that the necessary assumptions underlying the statistical methodology were assessed and met.ResultsFrom the 470 studies that were reviewed, the most common statistical test reported was the independent-samples t-test (n=215, 45.7%). Also, 201 studies (42.8%) implemented some form of regression analysis. The most common regression was a logistic regression (n= 106). None of the 201 studies using regression analysis reported meeting all of the necessary assumptions to appropriately use a regression test.ConclusionMany recent studies published in JBJS depended on regression analyses to reach their conclusions, but none fully reported the necessary assumptions of these tests. Orthopaedic surgery journals should be more transparent in reporting the methodology of statistical tests, and readers must beware of possible gaps in statistical methodology and critically evaluate the studies' findings.

Comparative Studies in the Shoulder Literature Lack Statistical Robustness: A Fragility Analysis

PurposeEvidenced-based decision-making is rooted in comparative clinical studies; however, a small number of outcome event reversals have the potential to change study significance. The purpose of this study was to determine the utility of applying fragility analysis to comparative studies in the published orthopaedic shoulder literature.MethodsComparative clinical shoulder research studies reporting 1:1 dichotomous categorical data were analyzed in 6 leading orthopaedic journals between 2006 and 2016. Statistical significance was defined as a P value of less than .05. The fragility index (FI) for each study outcome was determined by the number of event reversals required to change the P value to either greater or less than 0.05, thus changing the study conclusions. The associated fragility quotient (FQ) was determined by dividing the FI by the total population comprising a particular outcome.ResultsOf the 23,897 studies screened, 3,591 met search criteria, with 198 comparative studies ultimately included for analysis, 67 of which were randomized controlled trials. There were 357 total outcome events with 74 reported as significant and 283 as not significant. The FI was 4 (IQR 2-6) with an associated FQ of 0.066 (interquartile range [IQR] 0.038-0.102). There was no difference in statistical fragility between randomized and nonrandomized trials with both revealing a FI of 4 and FQ of 0.068 (IQR 0.044-0.107) and 0.065 (IQR 0.031-0.101), respectively.ConclusionsThis current analysis reveals that comparative shoulder studies published in six leading orthopaedic journals are at risk of statistical fragility. As such, contemporary clinical shoulder literature may not be as robust as traditionally perceived with the reversal of only a few outcome events required to change study significance. Therefore, we advocate the reporting of both FI and FQ in addition to the P value as statistical complements to all comparative investigations to provide a more comprehensive understanding of trial stability and significance in the published shoulder literature.Clinical RelevanceComparative study designs are commonly employed in shoulder research. Several studies in both the general medical and orthopaedic literature have identified a lack of statistical robustness through comprehensive fragility analysis. Our findings demonstrate the P value may be an inadequate independent statistical metric requiring the complement of a FI and FQ to aid in the interpretation and understanding of study significance for clinical decision-making.

The Fragility of Statistical Significance in Patellofemoral Instability Research: A Systematic Review

Background: Fragility analysis is increasingly utilized to evaluate the robustness of results within the orthopaedic literature and has frequently revealed instability of reported outcomes. Purpose/Hypothesis: The purpose of this investigation was to utilize a fragility analysis to evaluate the stability of reported results in the patellofemoral instability (PFI) literature. We hypothesized the demonstration of significant fragility in patellofemoral research to be similar to that identified throughout other areas of the orthopaedic literature. Study Design: Systematic review; Level of evidence, 4. Methods: The PubMed database was queried from January 1, 2000, to October 10, 2020 for comparative trials in 10 prominent orthopaedic journals that reported dichotomous outcomes related to the management of PFI. The fragility index (FI) and the fragility quotient (FQ) were calculated for each individual outcome event, and the overall FI and FQ were determined for all included studies. Results: A total of 22 comparative studies comprising 11 randomized controlled trials and 11 nonrandomized trials were included for the analysis. A total of 75 outcome events underwent a fragility analysis and revealed a median FI and FQ of 3 (interquartile range [IQR], 1-5) and 0.043 (IQR, 0.018-0.081), respectively. Also 27% of included studies reported loss to follow-up greater than the overall FI, therefore suggesting the maintenance of the follow-up may have resulted in the reversal of significance. Conclusion: The result of the comprehensive fragility analysis demonstrated a lack of robustness in PFI research with the alteration of only a few outcome events required to reverse statistical significance. We therefore recommend the triple reporting of the P value, the FI, and the FQ to aid in the interpretation of the statistical integrity of future comparative trials in the PFI literature.

Are Oral Antibiotics an Effective Alternative to Intravenous Antibiotics in Treatment of Osteomyelitis of the Jaw?

Osteomyelitis of the jaw (OMJ) is unlike osteomyelitis of long bone. It presents unique challenges to treatment due to odontogenic pathways of infection, polymicrobial nature, and need to preserve facial form and function. The majority of osteomyelitis research comes from orthopedic literature. Thus, there is limited guidance for antibiotic administration in OMJ when treated with surgical management1. Current recommendations suggest 6 weeks of intravenous (IV) antibiotics are necessary for resolution of infection2. However, there are numerous complications associated with IV therapy. Recent orthopedic literature has shown oral (PO) is noninferior to IV antibiotic therapy for complex orthopedic infection. The purpose of this study was to review cases of OMJ treated with surgery and adjunctive antibiotics and determine whether antibiotic route (PO versus IV) and/or length of administration impacted resolution of infection.The investigators designed a retrospective cohort study and enrolled a sample of patients treated at Harborview Medical Center (HMC) from January 1st 2009 to December 31st 2019. (STUDY00007337). The primary predictor variable was antibiotic administration route: oral (PO) only, intravenous (IV) only, IV transitioned to oral (IV+PO), or none. The secondary predictor was duration of antibiotic therapy (≤6 weeks or >6 weeks). The primary outcome variable was resolution of infection, deemed as clinical and radiographic resolution. The secondary outcome variable was number of operative interventions to resolution of infection. Statistical analysis was performed using IBM SPSS 27.0 (SPSS, Inc, Chicago, IL). Descriptive, bivariate, and multiple linear regression statistics were computed, with statistical significance set at p < 0.05.Sixty-seven subjects met the inclusion criteria (38 male), mean age 51 years (18-88). Forty-nine (73%) were treated with PO antibiotics only, 12 (18%) with IV+PO, 3 (4%) with IV only, and 3 (4%) received none. Both PO and IV antibiotics were significantly associated with clinical resolution (p=0.022, 0.005, respectively), compared to debridement alone. However, antibiotic duration of ≤6 weeks compared to >6 weeks was not significant. The majority (84% [41 out of 49]) of PO subjects achieved resolution with one surgery. Eight of 49 (16%) required additional surgeries with a mean of 1.27 (1-4). Fifteen (22%) subjects received IV antibiotics, including subjects who were in the IV only and IV+PO categories. Three of 15 (20%) were IV only, and 12 of 15 (80%) were IV+PO – meaning they were discharged with variable lengths of IV antibiotics and transitioned to PO. Seven of 15 (46%) had clinical resolution after one surgery, while 8 (54%) required additional procedures with a mean of 1.87 (1-5). Identified sources of OMJ were odontogenic (59%), trauma (31%), or dental implant-associated (13%). In the multivariate logistic regression, PO antibiotics were positively associated with clinical outcome (p=0.025, OR=5.05). Regardless of the length of antibiotic therapy, PO subjects were approximately 5 times more likely have clinical resolution without additional surgery. Penicillin allergy (p=0.049, OR=0.223) and diabetes (p=0.008, OR=0.104) were adversely associated with clinical resolution.OMJ can be successfully treated with PO antibiotics and appropriate surgery. IV therapy did not offer an advantage over PO medication in our cohort and is known to be associated with increased complications and cost. While further studies with larger cohorts are recommended, reflexively prescribing 6 weeks of IV antibiotics as preliminary therapy seems antiquated. Clinicians should consider oral penicillins as first line whenever possible.

Patient-Reported Outcomes and Factors Associated with Achieving the Minimal Clinically Important Difference After ACL Reconstruction: Results at a Mean 7.7-Year Follow-up.

Background:Analyzing outcomes and the minimal clinically important difference (MCID) after anterior cruciate ligament reconstruction (ACLR) is of increased interest in the orthopaedic literature. The purposes of this study were to report outcomes after ACLR at medium to long-term follow-up, identify the threshold preoperative outcome values that would be predictive of achieving the MCID postoperatively, and analyze outcome maintenance at medium to long-term follow-up after ACLR.Methods:Active athletes who underwent ACLR were identified in an institutional ACL registry. Patient-reported outcome measures (PROMs) were administered preoperatively and at the 2-year and >5-year postoperative follow-up; measures included the International Knee Documentation Committee (IKDC) form, the 12-item Short Form Health Survey (SF-12) Physical Component Summary (PCS) and Mental Component Summary (MCS), and Lysholm scale. We calculated the MCID from baseline to each of the 2 follow-up periods (2-year and mean 7.7-year). Logistic regression was performed to investigate factors associated with achievement of the MCID.Results:A total of 142 patients (mean follow-up, 7.7 years [range, 6.6 to 9.1 years]) underwent ACLR. The mean age and body mass index at the time of surgery were 27.2 ± 13.0 years and 23.2 ± 3.0 kg/m2, respectively. Final postoperative outcome scores improved significantly from baseline for the IKDC (50.9 ± 14.7 to 87.9 ± 11.2), SF-12 PCS (41.6 ± 8.9 to 55.6 ± 3.2), and Lysholm scale (62.2 ± 17.6 to 90.5 ± 10.3) (p < 0.0001), while the SF-12 MCS did not improve significantly (54.2 ± 8.0 to 54.4 ± 6.0) (p = 0.763). Between 2- and >5-year follow-up, the SF-12 PCS showed significant improvement (54.6 ± 4.5 to 55.6 ± 3.2; p = 0.036), while no change was noted in the IKDC (87.6 ± 11.1 to 87.9 ± 11.2), SF-12 MCS (55.5 ± 5.3 to 54.4 ± 6.0), and Lysholm scale (89.8 ± 10.6 to 90.5 ± 10.3) (p ≥ 0.09). At the time of final follow-up, the MCID was achieved by 94.7% of patients for the IKDC, 80.8% for the Lysholm, 79.0% for the SF-12 PCS, and 28.2% for the SF-12 MCS. At 2-year follow-up, 95.3% of patients were either “very” or “somewhat” satisfied with their surgery, compared with 88.6% at the time of final follow-up.Conclusions:We found a high level of maintained function following ACLR. The IKDC, SF-12 PCS, and Lysholm scores improved significantly after ACLR at the time of final follow-up and were not significantly different between follow-up periods. Approximately 95% and 89% of patients reported being satisfied with the outcome of surgery at the 2-year and final follow-up, respectively.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Predicting Reparability of Meniscal Tears Pre-Operatively Using 3-Tesla MRI (111)

Objectives:The ability to predict meniscus tear reparability based on pre-operative MRI is desirable for pre-operative patient counseling. However, the accuracy of MRI-based predictive methods varies widely within the orthopedic and radiology literature. We hypothesized that modern higher resolution 3-Tesla (T) MRI improves the accuracy of predicting reparability compared to prior investigations using 1.5T MRI assessments.Methods:We identified 44 patients (age 16 to 40 years) who were known to have undergone arthroscopic meniscal repair at our institution between the dates of January 1, 2013 and June 1, 2019. The MRI characteristics of this meniscus repair group were then compared to 43 age- and sex-matched patients who underwent arthroscopic partial meniscectomy during the same time period. 3T MRI images from the repair (Figure 1A) and the partial meniscectomy (Figure 1B) groups were all obtained pre-operatively at the author’s institution. Images from all 87 patients were independently reviewed by two fellowship-trained musculoskeletal radiologists and one orthopedic surgery fellow specializing in sports medicine. Each examiner was blinded with regard to meniscus tear treatment (repair versus partial meniscectomy). Meniscal tear MRI characteristics were evaluated based on established arthroscopic criteria including tear length greater than 10 mm, tear location within 3 mm of the menisco-synovial junction, tear greater than 50% thickness, and the presence of an intact inner meniscal fragment. We then analyzed the predictive accuracy and interrater reliability of this method.Results:With regards to accurately predicting meniscal reparability using the established criteria, the three MRI examiners accurately predicted repair 58% (orthopedist), 60% (radiologist 1), and 63% (radiologist 2) of the time, with respective positive predictive values of 60%, 62%, and 70%. The three examiners agreed upon tear reparability (i.e., a score of 4 versus not 4) only 41% of the time (κ = 0.173, p = .005). For 2 of the examiners (orthopedist and radiologist), none of the individual criteria were significantly predictive of tear reparability. For the 3rd examiner (radiologist), tear location within 3mm of the meniscosynovial junction was the most predictive individual criterion and the only criteria that reached statistical significance (OR = 9.83, p = .04).Conclusions:Although 3T MRI is higher resolution than 1.5T MRI, 3T MR imaging assessments performed by experienced examiners demonstrated a poor ability to predict the reparability of meniscus tears based on the application of previously established arthroscopic criteria. In addition, inter-observer reliability in this setting was also poor. Arthroscopic inspection remains the gold standard for the determination of meniscus tear reparability.

360 Safety and Depth of Sedation With Ketamine Alone versus Ketamine With Midazolam in Pediatric Fracture Reduction: A Retrospective Chart Review

Pediatric patients with extremity fractures often require sedation for fracture reduction in the pediatric emergency department (PED). While orthopedic literature suggests combination sedation regimens may be more effective for fracture reduction, some pediatric literature suggests adverse events are more frequent. The primary objective of this study is to determine the comparable depth of sedation and incidence of adverse events when intravenous ketamine is used alone versus with midazolam for pediatric procedural sedation and orthopedic fracture reduction. This is a retrospective cohort study of pediatric patients 2-18 years old who underwent sedation for fracture reduction in the PED at a single Level 1 Trauma center over a two-year period. Medical records were reviewed, and occurrence of adverse events, depth of sedation (Ramsey score), midazolam dose, total ketamine administration, opiate administration, total sedation time, and time to PED discharge were compared in patients who received ketamine alone versus ketamine with midazolam. Logistic regression models were adjusted to evaluate for potential confounders. There was a statistically significant increase in the occurrence of hypoxia with co-administration of midazolam (5% vs 0%). When hypoxia occurred, it was mild and resolved with repositioning or administration of supplemental oxygen. Length of sedation was increased in sedations with co-administration of benzodiazepines by approximately 4.5 minutes. Time to PED discharge was not significantly different. There was no significant difference in depth of sedation, ketamine dose administered, end-tidal CO2 measurements, administration of positive pressure ventilation (PPV), vomiting, agitation, or overall occurrence of adverse events. No patients developed apnea or laryngospasm. This study showed a low rate of adverse events in pediatric sedation for orthopedic reduction with ketamine alone or ketamine with midazolam. There was an increased occurrence of hypoxia with co-administration of midazolam, and an increase in the length of sedation. This study showed no difference in depth of sedation based on Ramsay scores when midazolam was co-administered. Information on the orthopedic reduction and provider satisfaction was not collected.

Fragility Index as a Measure of Randomized Clinical Trial Quality in Adult Reconstruction: A Systematic Review.

BackgroundThe Fragility Index (FI) and Reverse Fragility Index are powerful tools to supplement the P value in evaluation of randomized clinical trial (RCT) outcomes. These metrics are defined as the number of patients needed to change the significance level of an outcome. The purpose of this study was to calculate these metrics for published RCTs in total joint arthroplasty (TJA).MethodsWe performed a systematic review of RCTs in TJA over the last decade. For each study, we calculated the FI (for statistically significant outcomes) or Reverse Fragility Index (for nonstatistically significant outcomes) for all dichotomous, categorical outcomes. We also used the Pearson correlation coefficient to evaluate publication-level variables.ResultsWe included 104 studies with 473 outcomes; 92 were significant, and 381 were nonstatistically significant. The median FI was 6 overall and 4 and 7 for significant and nonsignificant outcomes, respectively. There was a positive correlation between FI and sample size (R = 0.14, P = .002) and between FI and P values (R = 0.197, P = .000012).ConclusionsThis study is the largest evaluation of FI in orthopedics literature to date. We found a median FI that was comparable to or higher than FIs calculated in other orthopedic subspecialties. Although the mean and median FIs were greater than the 2 recommended by the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines to demonstrate strong evidence, a large percentage of studies have an FI < 2. This suggests that the TJA literature is on par or slightly better than other subspecialties, but improvements must be made.Level of EvidenceLevel I; Systematic Review.

Inconsistencies in Controlling for Risk Factors for Recurrent Shoulder Instability After Primary Arthroscopic Bankart Repair: A Systematic Review

Background: Failure rates after arthroscopic shoulder stabilization are highly variable in the current orthopaedic literature. Predictive factors for risk of failure have been studied to improve patient selection, refine surgical techniques, and define the role of bony procedures. However, significant heterogeneity in the analysis and controlling of risk factors makes evidence-based management decisions challenging. Purpose: The goals of this systematic review were (1) to critically assess the consistency of reported risk factors for recurrent instability after arthroscopic Bankart repair, (2) to identify the existing studies with the most comprehensive inclusion of confounding factors in their analyses, and (3) to give recommendations for which factors should be reported consistently in future clinical studies. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature was performed in accordance with the PRISMA guidelines. An initial search yielded 1754 titles, from which 56 full-text articles were screened for inclusion. A total of 29 full-text articles met the following inclusion criteria: (1) clinical studies regarding recurrent anterior shoulder instability; (2) surgical procedures performed including arthroscopic anterior labral repair; (3) reported clinical outcome data including failure rate; and (4) assessment of risk factors for surgical failure. Further subanalyses were performed for 15 studies that included a multivariate analysis, 17 studies that included glenoid bone loss, and 8 studies that analyzed the Instability Severity Index Score. Results: After full-text review, 12 of the most commonly studied risk factors were identified and included in this review. The risk factors that were most consistently significant in multivariate analyses were off-track lesions (100%), glenoid bone loss (78%), Instability Severity Index Score (75%), level of sports participation (67%), number of anchors (67%), and younger age (63%). In studies of bone loss, statistical significance was more likely to be found using advanced imaging, with critical bone loss thresholds of 10% to 15%. Several studies found predictive thresholds of 2 to 4 for Instability Severity Index Score by receiver operating characteristic or multivariate analysis. Conclusion: Studies reporting risk factors for failure of arthroscopic Bankart repair often fail to control for known confounding variables. The factors with the most common statistical significance among 15 multivariate analyses are off-track lesions, glenoid bone loss, Instability Severity Index Score, level of sports participation, number of anchors, and younger age. Studies found significance more commonly with advanced imaging measurements or arthroscopic assessment of glenoid bone loss and with lower thresholds for the Instability Severity Index Score (2-4). Future studies should attempt to control for all relevant factors, use advanced imaging for glenoid bone loss measurements, and consider a lower predictive threshold for the Instability Severity Index Score.

The Forward Movement: Amplifying Black Voices on Race and Orthopaedics-Disparity Studies Should Not Ignore America's Racial History.

Our patients and the public at large carry high expectations for surgeons as effective problem solvers. Rightfully so. Identifying the root cause of a problem and efficiently working to resolve it are both prerequisites to the successful practice of orthopaedics. This is stressed upon us through the many rites of passage in our training. We take personal pride in it. And yet, when asked to apply the same level of discernment to racial health disparities, we fall dreadfully short. We have not successfully applied our immense insight to a public-health crisis staring directly in our collective face. The societal impact of fragility hip fractures in older adults is tremendous. By some estimates, the 1-year mortality rate after a hip fracture may reach 20% [6]. Many patients suffer decreases in fine motor, mobility, and cognitive status after hip fracture treatment [2]. Moreover, the societal cost of hip fractures has been estimated as high as USD 20 billion per year [3]. And as is commonly the case in the United States healthcare system, Black patients are at disproportionately higher risk for poorer outcomes after hip fracture. Black patients with hip fractures wait longer for their radiographs [1] and for their operations [1, 7]. Perhaps not surprisingly, they’re also more likely to experience complications following this severe injury [1, 4, 7]. These disparities suggest an access-to-care issue. What is its root cause? Studies on healthcare disparities often point a finger at unconscious bias and suggest the importance of a more diverse physician workforce. All good thoughts. But I challenge our field to take a closer look. By the time an older patient arrives in the emergency department with a hip fracture, a host of societal factors have already helped to put her there. And until there is a better understanding of the role race plays in that trajectory, orthopaedic surgery will continue to undertreat and mistreat Black patients. A critical evaluation of America’s racial past provides needed perspective. In the early 20th Century, millions of Black American families migrated from the rural South to urban centers of the Midwest, West Coast, and Northeast to escape the racial terrorism of the Jim Crow South, in what sometimes has been called the Great Migration [5]. Unfortunately, in these new locations, families were subjected to the same racism, albeit in a different form. The response to the influx of Black Americans in urban centers was systematic segregation. Through tactics such as redlining, legal and illegal methods were used to relegate Black families into the least-desirable parts of town. Subsequently, employment opportunities and access to public services were systematically removed from the segregated Black neighborhoods. The end result was the unfair and methodical exclusion of Black families in urban centers from important opportunities. The effects of these actions are felt to this day and are reflected in disparities in employment, housing, access to nutrition, and, of course, access to healthcare. This did not occur by accident or misunderstanding. So to say that Black patients in a Baltimore hospital waited longer for radiographs or hip fracture repair [1] without giving this historical context is inadequate. It is inadequate unless it is paired with a comprehension of the intentional societal efforts to marginalize the Black Americans of that community. It is inadequate unless it acknowledges the direct hand that structural discrimination has played in limiting Black patients’ access to expedient hip fracture care. It is inadequate until these realizations are utilized to reverse the effects of systemic racism. We need to change the way we frame the discussion of racial healthcare disparity in our orthopaedic literature. When we note disparate outcomes for Black patients in our investigations, we need to make it clear that this is not a matter of happenstance. We need to discuss the historical and societal factors that brought them about. The way forward can take many different forms (acknowledgement in discussion, extended discussion via commentaries, in-person topic discussions). But at the very least, in the study itself, the Discussion section of an orthopaedic health disparity study should address the how and the why or risk dehumanizing the people who are suffering. Out of respect for the communities that have been hurt, we must acknowledge that these findings are the direct results of intentional historical action and inaction. The clearer the picture we can paint of the root-cause of the problem, the more effectively we can partner with the public to bring it to an end.

Quality of reporting for pilot randomized controlled trials in the pediatric urology literature–A systematic review

The conduct and reporting of pilot studies is important to assess the feasibility of future randomized controlled trials (RCT). The Consolidated Standards of Reporting Trials (CONSORT) statement extension to pilot/feasibility studies addresses the reporting quality of the pilot studies (Summary Table 1). The aims of this systematic review are (1) to assess the reporting quality of pilot studies in pediatric urology and (2) to explore the factors that are associated with the reporting quality of these studies. A comprehensive search was conducted through MEDLINE® and EMBASE® to identify pilot RCTs from 2005 to 2018. Two reviewers independently performed title and abstract screening and full text review, with discrepancies resolved by consensus. CONSORT extension reported items were summarized and overall proportion of reported items for each article was estimated. A linear regression model was conducted to determine factors associated with higher reporting quality. Publication year, biostatistician/epidemiologist support, sample size justification and journal impact factor were collected. Of the 1463 titles duplicates were removed and 1347 were screened, 36 studies were included. Overall, 36 pilot studies reported about 8-9 of 17 items [51% (95% CI: 46 - 56%)]. The most reported items were contact details for the corresponding author (97%), title identification of study as randomised pilot or feasibility trial (95%), eligibility criteria and setting (81%), both interventions (78%), and specific objectives of the pilot trial (75%). Less fulfilled items were blinding (11%), registration of the trial (11%), randomization details (28%), detailing recruitment status in the pilot study (19%), trial design (31%), and source of funding for pilot trial (34%). Interpretation of the results of pilot trial and their implications for the future definitive trial was reported by 34% of the studies. Factors associated with higher reporting quality were the presence of biostatistician or epidemiologist (P=0.004), and if the sample size for the pilot study was justified (P=0.002). Overall reporting quality of pilot studies in pediatric urology literature from 2005-2018 was suboptimal. The quality of pilot RCTs included in the present review were lower than that observed in the orthopedic literature, however, it appears to be consistent with the trends regarding OQS in chronic kidney disease and allopathic medicine. While we endeavoured to maintain utmost rigidity of this systematic review, there are inherent limitations. The CONSORT 2010 extension for pilot RCTs was published in 2016. Clinical trials can take several years, many pilot studies published pre-2016 would not have had the guidance of the extension during designing phases. Not all pilot RCTs are published, so this could potentially reduce the generalizability of the findings from this review. Only studies in English, published in full peer-reviewed journals were included, and this review only addressed the reporting quality of pilot studies in pediatric urology. This review demonstrated that reporting quality of pilot studies in pediatric urology is currently suboptimal. Including biostatistician and/or epidemiologist, can ameliorate the quality of future pilot studies. Implementing CONSORT 2010 extension by journals as a prerequisite for submission of pilot or feasibility trials is recommended to improve the robustness and transparency of future pilot studies.

Current Trends in Orthobiologics: An 11-Year Review of the Orthopaedic Literature

Background: The use of “orthobiologics” or regenerative therapies in orthopaedic surgery has grown in recent years. Particular interest has been raised with regard to platelet-rich plasma, bone marrow aspirate, adipose-derived cells, and amniotic cells. Although studies have analyzed outcomes after orthobiologic treatment, no study has analyzed how the literature as a whole has evolved. Purpose: To evaluate trends in platelet-rich plasma, bone marrow aspirate, adipose-derived cells, and amniotic cell publications and to assess how these might inform efforts to establish minimum reporting standards and forecast future use. Study Design: Systematic review; Level of evidence, 4. Methods: A database was compiled systematically using PubMed to identify articles published between 2009 and 2019 within 9 prominent orthopaedic journals and pertaining to the use of platelet-rich plasma, bone marrow aspirate, adipose-derived cells, and amniotic cells in the treatment of musculoskeletal conditions. Included articles were classified as clinical, nonclinical (translational or basic science), or review, and a variety of study parameters were recorded for each. Additional queries were performed to identify articles that utilized minimum reporting standards. Results: A total of 474 articles (132 clinical, 271 nonclinical, 71 review) were included, consisting of 244 (51.5%) platelet-rich plasma, 146 (30.8%) bone marrow aspirate, 72 (15.2%) adipose-derived cells, and 12 (2.5%) amniotic cells. The greatest annual increase in publications for each orthobiologic topic was from 2018 to 2019. The American Journal of Sports Medicine demonstrated the highest number of overall (34.2%) and clinical (50.0%) publications, and accounted for 44.3% of all platelet-rich plasma publications. The Journal of Orthopaedic Research accounted for the second highest overall number of publications (24.9%) and highest nonclinical publications (41.0%). Platelet-rich plasma accounted for 91.5% of all level 1 clinical studies, while much greater than half of bone marrow aspirate, adipose-derived cells, and amniotic cell publications were level 3 or lower. Out of the 207 articles that used some form of reporting protocol, 59 (28.5%) used an established algorithm and 125 (60.4%) used their own. Conclusion: Interest in orthobiologics continues to grow, as evidenced by an increasing trend in publications over an 11-year period. However, current reporting on orthobiologic formulations is largely heterogeneous, emphasizing the need for minimum reporting standards and higher-quality studies.