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Objective By aggregating the literature, we evaluated the association between use of specific antihypertensive drugs and the risk of hip fractures compared with nonuse. Study design and setting We systematically searched the Pubmed, Embase, and Cochrane databases from inception of each database until July 30, 2020 to identify articles including patients 18 years of age or older reporting on the association between antihypertensive drugs and the risk of hip fracture. Antihypertensive drugs were restricted to thiazides; beta-blockers; calcium-channel blockers; angiotensin-converting enzyme (ACE) inhibitors; and angiotensin receptor blockers. Nonusers encompass all patients that are not using the specific antihypertensive drug that has been reported. Unadjusted odds ratios with 95% confidence intervals (CIs) of the association between antihypertensive drug use and hip fractures were reported. Meta-analysis was performed when a minimum of five studies were identified for each antihypertensive drug class. Quality assessment was done using ROBINS-I tool. The GRADE approach was used to evaluate the certainty of the evidence. Results Of 962 citations, 22 observational studies were included; 9 studies had a cohort design and 13 studies were case-control studies. No randomized controlled trials were identified. We found very low certainty of evidence that both thiazides (pooled odds ratio: 0.85, 95% CI 0.73 to 0.99, p = 0.04) as well as beta-blockers (pooled odds ratio: 0.88, 95% CI 0.79 to 0.98, p = 0.02) were associated with a reduced hip fracture risk as compared to specific nonuse. One study, reporting on angiotensin receptor blockers, also suggested a protective effect for hip fractures, whereas we found conflicting findings in four studies for calcium-channel blockers and in two studies for ACE inhibitors. Conclusion Among 22 observational studies, we found very low certainty of evidence that, compared to specific nonuse of antihypertensive drugs, use of thiazides, beta-blockers, and angiotensin receptor blockers were associated with a reduced protective hip fracture risk, while conflicting findings for calcium-channel blockers and ACE inhibitors were found. Given the low quality of included studies, further research –randomized controlled trials– are needed to definitively assess the causal relationship between specific antihypertensive drug classes and (relatively infrequent) hip fractures.

Purpose To assess the proportion, nature, and extent of financial payments from industry to residency program directors in the United States. Method This cross-sectional study used opensource data from Doximity and the Centers for Medicare and Medicaid (CMS) open payments database. Profiles of 4,686 residency program directors from 28 different specialties were identified using Doximity and matched to records in the CMS database. All payments received per residency program director over the years 2014 to 2018 were extracted, including amount in U.S. dollars, payment year, and nature of payment (research versus general payments). Total payments (research plus general payments) received over the 5 years were added up per residency program director. Only personal payments were included. Results Overall, 74% (3,465/4,686) of all residency program directors received 1 or more personal payments, totaling $77,058,139, with a median of $216 (interquartile range, $0-$2,150) and a mean of $16,444 (standard deviation, $183,061) per residency program director over the 5 years. Ninety-five percent of total payment value were general payments, and 5% were personal research payments. About 11% (536/4,686) of residency program directors received more than $10,000, while 3% (133/4,686) received more than $100,000 in the study years. There was a substantial difference in the proportion (P < .001), nature (P < .001), and amount (P < .001) of payments of residency program directors between specialties. Almost all residency program directors of interventional radiology (96% [74/77]), vascular surgery (96% [53/55]), and orthopedic surgery (92% [184/201]) received payments, while only one-third to one-half of those in preventive medicine (29% [18/62]), pediatrics (43% [90/211]), and pathology (51% [73/143]) received payments. Conclusions Industry payments to residency program directors are common, although large variation exists between specialties. The majority of direct payments to residency program directors are for non-researchrelated activities.

BACKGROUND The outcome differences following surgery for an impending versus a completed pathological fracture have not been clearly defined. The purpose of the present study was to assess differences in outcomes following the surgical treatment of impending versus completed pathological fractures in patients with long-bone metastases in terms of (1) 90-day and 1-year survival and (2) intraoperative blood loss, perioperative blood transfusion, anesthesia time, duration of hospitalization, 30-day postoperative systemic complications, and reoperations. METHODS We retrospectively performed a matched cohort study utilizing a database of 1,064 patients who had undergone operative treatment for 462 impending and 602 completed metastatic long-bone fractures. After matching on 22 variables, including primary tumor, visceral metastases, and surgical treatment, 270 impending pathological fractures were matched to 270 completed pathological fractures. The primary outcome was assessed with the Cox proportional hazard model. The secondary outcomes were assessed with the McNemar test and the Wilcoxon signed-rank test. RESULTS The 90-day survival rate did not differ between the groups (HR, 1.13 [95% CI, 0.81 to 1.56]; p = 0.48), but the 1-year survival rate was worse for completed pathological fractures (46% versus 38%) (HR, 1.28 [95% CI, 1.02 to 1.61]; p = 0.03). With regard to secondary outcomes, completed pathological fractures were associated with higher intraoperative estimated blood loss (p = 0.03), a higher rate of perioperative blood transfusions (p = 0.01), longer anesthesia time (p = 0.04), and more reoperations (OR, 2.50 [95% CI, 1.92 to 7.86]; p = 0.03); no differences were found in terms of the rate of 30-day postoperative complications or the duration of hospitalization. CONCLUSIONS Patients undergoing surgery for impending pathological fractures had lower 1-year mortality rates and better secondary outcomes as compared with patients undergoing surgery for completed pathological fractures when accounting for 22 covariates through propensity matching. Patients with an impending pathological fracture appear to benefit from prophylactic stabilization as stabilizing a completed pathological fracture seems to be associated with increased mortality, blood loss, rate of blood transfusions, duration of surgery, and reoperation risk. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Unicompartmental knee arthroplasty (UKA) has several advantages over total knee arthroplasty; however, in many reports, the risk of revision remains higher after UKA. Many reasons for failure of UKA exist. Successful treatment starts with accurate assessment of the symptomatic UKA as a specific mode of failure requires a specific solution. A structured and comprehensive evaluation aids assessment of the symptomatic UKA. This review provides an overview of the causes for a symptomatic medial UKA, its risk factors, diagnostic modalities that can be used, and briefly discusses treatment options. Cite this article: EFORT Open Rev 2021;6:850-860. DOI: 10.1302/2058-5241.6.200105

PurposeTo assess the feasibility of needle arthroscopy for management of suspected bacterial arthritis in native joints.MethodsDuring a pilot period, patients presenting with symptoms suggestive of native joint bacterial arthritis were eligible for initial management with needle arthroscopy. Procedures were performed in the operating theatre or at the patient bedside in the emergency department or inpatient ward. As our primary outcome measure, it was assessed whether needle arthroscopic lavage resulted in a clear joint. In addition, the need for conversion to standard arthroscopy or arthrotomy, the need for conversion from local to general anaesthesia, complications and the need for additional surgical intervention at follow-up during admission were recorded.ResultsEleven joints in 10 patients (four males, age range 35 – 77) were managed with needle arthroscopy. Needle arthroscopic lavage resulted in a clear joint in all cases. Conversion to standard arthroscopy or arthrotomy was not needed. Seven procedures were performed at the patient bedside using local anaesthesia. These procedures were well tolerated and conversion to general or spinal anaesthesia was not required. There were no procedure complications. One patient received multiple needle arthroscopic lavages. No further surgical interventions beside the initial needle arthroscopic lavage were required for successful management in other cases.ConclusionsNeedle arthroscopy can be a feasible tool in the initial management of complaints suggestive for native joint bacterial arthritis, providing an effective, quick and well-tolerable intervention in the operating theatre or at the patient bedside, with the potential to relief health systems from need for scarce operating theatre time.

Aims This study evaluated variation in the surgical treatment of stable (A1) and unstable (A2) trochanteric hip fractures among an international group of orthopaedic surgeons, and determined the influence of patient, fracture, and surgeon characteristics on choice of implant (intramedullary nailing (IMN) versus sliding hip screw (SHS)). Methods A total of 128 orthopaedic surgeons in the Science of Variation Group evaluated radiographs of 30 patients with Type A1 and A2 trochanteric hip fractures and indicated their preferred treatment: IMN or SHS. The management of Type A3 (reverse obliquity) trochanteric fractures was not evaluated. Agreement between surgeons was calculated using multirater kappa. Multivariate logistic regression models were used to assess whether patient, fracture, and surgeon characteristics were independently associated with choice of implant. Results The overall agreement between surgeons on implant choice was fair (kappa = 0.27 (95% confidence interval (CI) 0.25 to 0.28)). Factors associated with preference for IMN included USA compared to Europe or the UK (Europe odds ratio (OR) 0.56 (95% CI 0.47 to 0.67); UK OR 0.16 (95% CI 0.12 to 0.22); p < 0.001); exposure to IMN only during training compared to surgeons that were exposed to both (only IMN during training OR 2.6 (95% CI 2.0 to 3.4); p < 0.001); and A2 compared to A1 fractures (Type A2 OR 10 (95% CI 8.4 to 12); p < 0.001). Conclusion In an international cohort of orthopaedic surgeons, there was a large variation in implant preference for patients with A1 and A2 trochanteric fractures. This is due to surgeon bias (country of practice and aspects of training). The observation that surgeons favoured the more expensive implant (IMN) in the absence of convincing evidence of its superiority suggests that surgeon de-biasing strategies may be a useful focus for optimizing patient outcomes and promoting value-based healthcare. Cite this article: Bone Joint J 2021;103-B(4):775–781.

Background Evidence suggests that there is substantial and unexplained surgeon-to-surgeon variation in recommendation of operative treatment for fractures of the distal radius. We studied (1) what factors are associated with recommendation for operative treatment of a fracture of the distal radius and (2) which factors are rated as the most influential on recommendation of operative treatment. Methods One-hundred thirty-one upper extremity and fracture surgeons evaluated 20 fictitious patient scenarios with randomly assigned factors (e.g., personal, clinical, and radiologic factors) for patients with a fracture of the distal radius. They addressed the following questions: (1) Do you recommend operative treatment for this patient (yes/no)? We determined the influence of each factor on this recommendation using random forest algorithms. Also, participants rated the influence of each factor—excluding age and sex— on a scale from 0 (not at all important) to 10 (extremely important). Results Random forest algorithms determined that age and angulation were having the most influence on recommendation for operative treatment of a fracture of the distal radius. Angulation on the lateral radiograph and presence or absence of lunate subluxation were rated as having the greatest influence and smoking status and stress levels the lowest influence on advice to patients. Conclusions The observation that—other than age—personal factors have limited influence on surgeon recommendations for surgery may reflect how surgeon cognitive biases, personal preferences, different perspectives, and incentives may contribute to variations in care. Future research can determine whether decision aids—those that use patient-specific probabilities based on predictive analytics in particular—might help match patient treatment choices to what matters most to them, in part by helping to neutralize the influence of common misconceptions as well as surgeon bias and incentives. Level of Evidence There is no level of evidence for the study.

Background and purpose — There is ongoing debate as to whether commercial funding influences reporting of medical studies. We asked: Is there a difference in reported tones between abstracts, introductions, and discussions of orthopedic journal studies that were commercially funded and those that were not commercially funded? Methods — We conducted a systematic PubMed search to identify commercially funded studies published in 20 orthopedic journals between January 1, 2000 and December 1, 2019. We identified commercial funding of studies by including in our search the names of 10 medical device companies with the largest revenue in 2019. Commercial funding was designated when either the study or 1 or more of the authors received funding from a medical device company directly related to the content of the study. We matched 138 commercially funded articles 1 to 1 with 138 non-commercially funded articles with the same study design, published in the same journal, within a time range of 5 years. The IBM Watson Tone Analyzer was used to determine emotional tones (anger, fear, joy, and sadness) and language style (analytical, confident, and tentative). Results — For abstract and introduction sections, we found no differences in reported tones between commercially funded and non-commercially funded studies. Fear tones (non-commercially funded studies 5.1%, commercially funded studies 0.7%, p = 0.04), and analytical tones (non-commercially funded studies 95%, commercially funded studies 88%, p = 0.03) were more common in discussions of studies that were not commercially funded. Interpretation — Commercially funded studies have comparable tones to non-commercially funded studies in the abstract and introduction. In contrast, the discussion of non-commercially funded studies demonstrated more fear and analytical tones, suggesting them to be more tentative, accepting of uncertainty, and dispassionate. As text analysis tools become more sophisticated and mainstream, it might help to discern commercial bias in scientific reports.

Background For fracture care, radiographs and two-dimensional (2-D) and three-dimensional (3-D) CT are primarily used for preoperative planning and postoperative evaluation. Intraarticular distal radius fractures are technically challenging to treat, and meticulous preoperative planning is paramount to improve the patient's outcome. Three-dimensionally printed handheld models might improve the surgeon's interpretation of specific fracture characteristics and patterns preoperatively and could therefore be clinically valuable; however, the additional value of 3-D printed handheld models for fractures of the distal radius, a high-volume and commonly complex fracture due to its intraarticular configuration, has yet to be determined. Questions/purposes (1) Does the reliability of assessing specific fracture characteristics that guide surgical decision-making for distal radius fractures improve with 3-D printed handheld models? (2) Does surgeon agreement on the overall fracture classification improve with 3-D printed handheld models? (3) Does the surgeon's confidence improve when assessing the overall fracture configuration with an additional 3-D model? Methods We consecutively included 20 intraarticular distal radius fractures treated at a Level 1 trauma center between May 2018 and November 2018. Ten surgeons evaluated the presence or absence of specific fracture characteristics (volar rim fracture, die punch, volar lunate facet, dorsal comminution, step-off > 2 mm, and gap > 2 mm), fracture classification according to the AO/Orthopaedic Trauma Association (OTA) classification scheme, and their confidence in assessing the overall fracture according to the classification scheme, rated on a scale from 0 to 10 (0 = not at all confident to 10 = very confident). Of 10 participants regularly treating distal radius fractures, seven were orthopaedic trauma surgeons and three upper limb surgeons with experience levels ranging from 1 to 25 years after completion of residency training. Fractures were assessed twice, with 1 month between each assessment. Initially, fractures were assessed using radiographs and 2-D and 3-D CT images (conventional assessment); the second time, the evaluation was based on radiographs and 2-D and 3-D CT images with an additional 3-D handheld model (3-D printed handheld model assessment). On both occasions, fracture characteristics were evaluated upon a surgeon's own interpretation, without specific instruction before assessment. We provided a sheet demonstrating the AO/OTA classification scheme before evaluation on each session. Multi-rater Fleiss's kappa was used to determine intersurgeon reliability for assessing fracture characteristics and classification. Confidence regarding assessment of the overall fracture classification was assessed using a paired t-test. Results We found that 3-D printed models of intraarticular distal radius fractures led to no change in kappa values for the reliability of all characteristics: volar rim (conventional kappa 0.19 [95% CI 0.06 to 0.32], kappa for 3-D handheld model 0.23 [95% CI 0.11 to 0.36], difference of kappas 0.04 [95% CI -0.14 to 0.22]; p = 0.66), die punch (conventional kappa 0.38 [95% CI 0.15 to 0.61], kappa for 3-D handheld model 0.50 [95% CI 0.23 to 0.78], difference of kappas 0.12 [95% CI -0.23 to 0.47]; p = 0.52), volar lunate facet (conventional kappa 0.31 [95% CI 0.14 to 0.49], kappa for 3-D handheld model 0.48 [95% CI 0.23 to 0.72], difference of kappas 0.17 [95% CI -0.12 to 0.46]; p = 0.26), dorsal comminution (conventional kappa 0.36 [95% CI 0.13 to 0.58], kappa for 3-D handheld model 0.31 [95% CI 0.11 to 0.51], difference of kappas -0.05 [95% CI -0.34 to 0.24]; p = 0.74), step-off > 2 mm (conventional kappa 0.55 [95% CI 0.29 to 0.82], kappa for 3-D handheld model 0.58 [95% CI 0.31 to 0.85], difference of kappas 0.03 [95% CI -0.34 to 0.40]; p = 0.87), gap > 2 mm (conventional kappa 0.59 [95% CI 0.39 to 0.79], kappa for 3-D handheld model 0.69 [95% CI 0.50 to 0.89], difference of kappas 0.10 [95% CI -0.17 to 0.37]; p = 0.48). Although there appeared to be categorical improvement in kappa values for some fracture characteristics, overlapping CIs indicated no change. Fracture classification did not improve (conventional diagnostics: kappa 0.27 [95% CI 0.14 to 0.39], conventional diagnostics with an additional 3-D handheld model: kappa 0.25 [95% CI 0.15 to 0.35], difference of kappas: -0.02 [95% CI -0.18 to 0.14]; p = 0.81). There was no improvement in self-assessed confidence in terms of assessment of overall fracture configuration when a 3-D model was added to the evaluation process (conventional diagnostics 7.8 [SD 0.79 {95% CI 7.2 to 8.3}], 3-D handheld model 8.5 [SD 0.71 {95% CI 8.0 to 9.0}], difference of score: 0.7 [95% CI -1.69 to 0.16], p = 0.09). Conclusions Intersurgeon reliability for evaluating the characteristics of and classifying intraarticular distal radius fractures did not improve with an additional 3-D model. Further studies should evaluate the added value of 3-D printed handheld models for teaching surgical residents and medical trainees to define the future role of 3-D printing in caring for fractures of the distal radius. Level of evidence Level II, diagnostic study.

Introduction Cognitive biases are known to affect all aspects of human decision-making and reasoning. Examples include misjudgment of probability, preferential attention to evidence that confirms one's beliefs, and preference for certainty. It is not known whether cognitive biases influence orthopaedic surgeon decision-making. This study measured the influence of a few cognitive biases on orthopaedic decision-making in hypothetical vignettes. The questions we addressed were as follows: Do orthopaedic surgeons display the cognitive biases of base rate neglect and confirmation bias in hypothetical vignettes? Can anchoring and framing biases be demonstrated? Methods One hundred ninety-six orthopaedic surgeons completed a survey consisting of three vignettes evaluating base rate neglect, five evaluating confirmation bias, and two separate vignettes each randomly exposing half of the group to different anchors and frames. Results For the three vignettes evaluating base rate neglect, 43% (84 of 196) chose answers consistent with base rate neglect in vignette 1, 88% (173 of 196) in vignette 2, and 35% (69 of 196) in vignette 3. Regarding confirmation bias, 51% (100 of 196) chose an answer consistent with confirmation bias for vignette 1, 11% (22 of 196) for vignette 2, 22% (43 of 196) for vignette 3, 22% (44 of 196) for vignette 4, and 29% (56 of 196) for vignette 5. There was a measurable anchoring heuristic (56% versus 34%; a difference of 22%) and framing effect (77% versus 61%; a difference of 16%). Conclusion The influence of cognitive biases can be documented in patient vignettes presented to orthopaedic surgeons. Strategies can anticipate cognitive bias and develop practice debiasing strategies to limit potential error.

Using Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) computerized adaptive test instead of the Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) could reduce question burden for patients with knee pain. We aimed to prospectively determine the correlation between PROMIS PF and KOOS, JR to assess whether PROMIS PF could be a useful alternative measure for both research and clinical care of patients with knee pain. This was a cross-sectional study of 88 patients. We assessed the correlation between PROMIS PF and KOOS, JR using a Pearson's correlation test. Two multivariable linear regression models were used to determine the amount of variation explained by various patient-level factors. There was a strong correlation between PROMIS PF and KOOS, JR (r = 0.74, p

Introduction: The objective of this study is to determine factors associated with myonecrosis at the time of fasciotomy in patients with acute leg compartment syndrome. Methods: A retrospective cohort study was conducted of 546 patients with acute leg compartment syndrome treated with fasciotomies from January 2000 to June 2015 at two tertiary trauma centers. The main outcome measurement was clinical myonecrosis diagnosed by the treating surgeon at the time of fasciotomy. Results: Eighty-two patients (15.0%) with acute leg compartment syndrome had myonecrosis at time of fasciotomy. Multivariable logistic regression analyses showed that younger age (p = 0.004) and diabetes mellitus (p < 0.001) were associated with myonecrosis at time of fasciotomy in acute leg compartment syndrome. Serum creatine kinase at presentation greater than 2405 U/L was found to be associated with myonecrosis at time of fasciotomy in post hoc analysis (p < 0.001). Conclusions: Myonecrosis is associated with patient-related factors. Younger age by 10 years is associated with a 1.3 times increase and diabetes mellitus with a 3-time increase in the odds of myonecrosis. Serum creatine kinase at presentation greater than 2405 U/L denotes an almost 3 times increase in odds of myonecrosis and may be useful for preoperative counseling.

In this cadaveric study of anterior plating of the distal radius, we aimed to determine the interobserver agreement and diagnostic performance for detecting dorsally protruding screws using the dorsal tangential radiographic view before and after specific training. Without prior instruction, 13 observers interpreted the dorsal tangential view of cadaveric specimens, in which anterior radial plates were placed. After seeing a training video on the dorsal tangential view, they repeated the task. Though we found that accuracy and interobserver agreement was lower than described in some other clinical series, training led to statistically significant improvements of (1) the interobserver agreement on the decision to exchange screws, (2) the self-confidence of the surgeon in obtaining adequate views, and (3) the number of fluoroscopic images required to obtain these views. After training, the number of protruding screws missed was reduced by 36%, but 7% of dorsally protruding screws was still missed.

Introduction: The primary objective of this study is to determine whether time from injury to fasciotomy is associated with increased risk for death or limb amputation in patients with acute leg compartment syndrome. The secondary objective of this study is to identify other risk factors for death or limb amputation in patients with acute leg compartment syndrome. Methods: In an institutional review board approved retrospective study, we identified 546 patients with acute compartment syndrome of 558 legs treated with fasciotomies from January 2000 to June 2015 at two Level I trauma centers. Our primary outcome measures were death and limb amputation during inpatient hospital admission. Electronic medical records were analyzed for patient-related factors and treatment-related factors. Bivariate analyses were used to screen for variables associated with our primary outcome measures, and explanatory variables with a p value below 0.05 were included in our multivariable logistic regression analyses. Results: In-hospital death occurred in 6.6% and in-hospital limb amputation occurred in 9.5% of acute leg compartment syndrome patients. Neither death nor limb amputation was found to be associated with time from injury to fasciotomy. Multivariable logistic regression analyses showed that older age (p = 0.03), higher modified Charlson Comorbidity Index (p = 0.009), higher potassium (p = 0.02), lower hemoglobin (p = 0.002), and higher lactate (p < 0.001) were associated with death, and diabetes mellitus (p = 0.05), no compartment pressure measurement (p = 0.009), higher PTT (p = 0.03), and lower albumin (p = 0.01) were associated with limb amputation. Conclusions: Time to fasciotomy is not found to be associated with death or limb amputation in acute leg compartment syndrome. Death and limb amputation are associated with patient-related factors and injury severity. Level of evidence: Level III Prognostic.

PurposeDuring pronation, the distal biceps tendon and radial tuberosity internally rotate into the radioulnar space, reducing the linear distance between the radius and ulna by approximately 50%. This leaves a small space for the distal biceps tendon to move in and could possibly cause mechanical impingement or rubbing of the distal biceps tendon. Hypertrophy of the radial tuberosity potentially increases the risk of mechanical impingement of the distal biceps tendon. The purpose of our study was to determine if radial tuberosity size is associated with rupturing of the distal biceps tendon.MethodsNine patients with a distal biceps tendon rupture who underwent CT were matched 1:2 to controls without distal biceps pathology. A quantitative 3-dimensional CT technique was used to calculate the following radial tuberosity characteristics: 1) volume in mm3, 2) surface area in mm2, 3) maximum height in mm and 4) location (distance in mm from the articular surface of the radial head).ResultsAnalysis of the 3-dimensional radial tuberosity CT-models showed larger radial tuberosity volume and maximum height in the distal biceps tendon rupture group compared to the control group. Mean radial tuberosity volume in the rupture-group was 705 mm3(SD: 222 mm3) compared to 541 mm3(SD: 184 mm3) in the control group (p = 0.033). Mean radial tuberosity maximum height in the rupture-group was 4.6 mm (SD: 0.9 mm) compared to 3.7 mm (SD: 1.1 mm) in the control group, respectively (p = 0.011). There was no statistically significant difference in radial tuberosity surface area (ns) and radial tuberosity location (ns).ConclusionRadial tuberosity volume and maximum height were significantly greater in patients with distal biceps tendon ruptures compared to matched controls without distal biceps tendon pathology. This supports the theory that hypertrophy of the radial tuberosity plays a role in developing distal biceps tendon pathology.Level of evidenceLevel III.

Aims This study aimed to answer two questions: what are the best diagnostic methods for diagnosing bacterial arthritis of a native joint?; and what are the most commonly used definitions for bacterial arthritis of a native joint? Methods We performed a search of PubMed, Embase, and Cochrane libraries for relevant studies published between January 1980 and April 2020. Of 3,209 identified studies, we included 27 after full screening. Sensitivity, specificity, area under the curve, and Youden index of diagnostic tests were extracted from included studies. We grouped test characteristics per diagnostic modality. We extracted the definitions used to establish a definitive diagnosis of bacterial arthritis of a native joint per study. Results Overall, 28 unique diagnostic tests for diagnosing bacterial arthritis of a native joint were identified. The following five tests were deemed most useful: serum ESR (sensitivity: 34% to 100%, specificity: 23% to 93%), serum CRP (sensitivity: 58% to 100%, specificity: 0% to 96%), serum procalcitonin (sensitivity: 0% to 100%, specificity: 68% to 100%), the proportion of synovial polymorphonuclear cells (sensitivity: 42% to 100%, specificity: 54% to 94%), and the gram stain of synovial fluid (sensitivity: 27% to 81%, specificity: 99% to 100%). Conclusion Diagnostic methods with relatively high sensitivities, such as serum CRP, ESR, and synovial polymorphonuclear cells, are useful for screening. Diagnostic methods with a relatively high specificity, such as serum procalcitonin and synovial fluid gram stain, are useful for establishing a diagnosis of bacterial arthritis. This review helps to interpret the value of various diagnostic tests for diagnosing bacterial arthritis of a native joint in clinical practice. Cite this article: Bone Joint J 2021;103-B(12):1745–1753.

Background: Telemedicine in upper extremity surgery is an evolving modality that provides a viable alternative to the traditional in-person visit for achieving convenient, safe, and cost-effective ...

BACKGROUND: Patient reported outcome data in bone metastatic disease are scarce and it would be useful to have normative data and understand what patients are at risk for poor function and more pain. OBJECTIVES: We aimed to assess what factors are independently associated with physical function and pain intensity in patients with bone metastasis. METHODS: We included data from 211 patients with bone metastasis who completed a survey (2014-2016) including the PROMIS Physical Function Cancer and PROMIS Pain Intensity questionnaires. RESULTS: Prostate (P

Background There is growing interest in measuring and improving patient experience. Machine learning-based natural language processing techniques may help identify instructive themes in online comments written by patients about their healthcare provider. Separating individual surgeon and orthopaedic office reviews, we analyzed themes that are discussed based on the rating category, the association with review length, the number of people posting more than one review for a surgeon or office, the mean number of reviews per rating category, and the difference in review tones. Methods On Yelp.com, we collected 11,614 free-text reviews-together with a one- to five-star rating-of orthopaedic surgeons. Using natural language processing, we identified the most frequently occurring word combinations among rating categories. Themes were derived by categorizing word combinations. Dominant tones (emotional and language styles) were assessed by the IBM Watson Tone Analyzer. We calculated chi-square tests for linear trend and Spearman's rank correlation coefficients to assess differences among rating category. Results For individual surgeons and orthopaedic offices, themes such as logistics, care and compassion, trust, recommendation, and customer service varied among rating categories. More positive reviews are shorter for individual surgeons and orthopaedic offices, while rating category was comparable among people posting more than one review for both groups. Tones of joy and confidence were associated with higher ratings. Sadness and tentative tones were associated with lower ratings. Discussion For individual orthopaedic surgeons and orthopaedic offices, patient experience may be influenced mostly by the patient-clinician relationship. Training in more effective communication strategies may help improve self-reported patient experience.

Background: There is limited literature on risk stratification of patients with acute forearm compartment syndrome. The primary objective of this study was to identify factors associated with poor outcomes in patients with acute forearm compartment syndrome. Methods: We retrospectively identified 130 patients with acute compartment syndrome of 130 forearms treated with fasciotomies from January 2000 to June 2015 at 2 Level 1 trauma centers. Poor outcome was defined as a composite variable, including: (1) death; (2) limb amputation; (3) persistent neurological deficit; and (4) contracture. Patient- and treatment-related variables were collected. Bivariate analyses were used to screen for variables associated with poor outcome, and explanatory variables with a value of P < .05 were included in our multivariable logistic regression analyses. Results: Of the 130 patients, 43 (33%) with acute forearm compartment syndrome had poor outcomes, including 5 deaths, 5 limb amputations, 21 persistent neurological deficits, and 31 contractures. Multivariable logistic regression analyses showed that elevated serum creatine kinase at presentation ( P < .05) was associated with poor outcomes in patients with acute forearm compartment syndrome. Receiver operating characteristic curve analysis showed that a serum creatine kinase cutoff of 300 U/L yields 92% sensitivity and a serum creatine kinase cutoff of 10 000 U/L yields 95% specificity for poor outcomes in acute forearm compartment syndrome. Conclusions: Elevated creatine kinase levels above 300 U/L are a useful screening test for the highest risk patients with acute forearm compartment syndrome. Levels above 10 000 U/L may play a role in informed consent and counseling regarding expectations.

Introduction Salvage of infected tibia and fibula non-union and severe open fractures is challenging and often requires staged treatment. We describe all cases that underwent supercutaneous plating of the leg as external fixation technique and assessed union rate, time to union, rate of infection clearance, and patient-reported outcome measures. Methods This is a retrospective cohort study from a single level 1 trauma center. We included 19 patients that underwent supercutaneous plating—locking compression plate applied as external fixator—of the leg. Indications were: infected non-union of a pilon, cruris, or ankle fracture (n = 13); post-traumatic fistula draining osteomyelitis of the tibia (n = 3); infected mal-reduced subacute cruris fracture (n = 1); acute open pilon fracture (n = 1); and acute open cruris fracture (n = 1). Outcome measures were: union, time to union, infection clearance, the 36-item Short Form (SF-36) physical component summary scale (PCS) and mental component summary scale (MCS), and NRS pain scores. Results Union was achieved in 88% of the patients after a median of 279 days [interquartile range (IQR) 154–440]. Infection clearance was achieved in 94% of the patients. The PCS (median 51, IQR 46–56, p = 0.903) and MCS (median 57, IQR 50–60, p = 0.241) do not differ from normative population values. NRS Pain score at rest was 0 on average (IQR 0–1), 2 on average when walking (IQR 0–4), and 1 on average when climbing stairs (IQR 0–2). Conclusion Supercutaneous plating is a simple and reliable technical trick to bridge and stabilize a nonunion or fracture site while clearing an infection and have soft-tissues heal before subsequent definitive (internal)fixation and/or cancellous bone grafting. Reasonable union and infection clearance rates are achieved, and good functional outcome can generally be expected. Level of evidence Therapeutic level III.

Background The purpose of this study was to evaluate the impact of pronator quadratus (PQ) repair on reoperation rates after distal radius open reduction internal fixation (ORIF) using a volar locking plate. Methods A retrospective study of all patients undergoing distal radius ORIF with a volar locking plate between January 2012 and December 2016 at 2 urban, academic level I trauma centers was performed. Patient demographics, fracture and procedure characteristics, surgeon subspecialty, PQ repair, and reoperations were recorded. Descriptive statistics were used to determine whether patient-related or injury-related characteristics were associated with PQ repair. Bivariate and multivariable regression analyses were used to assess the effect of PQ repair on subsequent reoperations. Results In total, 509 patients were included, including 31 patients with bilateral injuries. The average follow-up time was 3.7 ± 2.8 years. Patients undergoing PQ repair were younger (57 ± 17 years vs 61 ± 17 years) and were more likely to have a lower Soong grade (53% vs 44% with Soong grade 0) than patients without PQ repair. Pronator quadratus repair was not found to have a significant impact on hardware removal, reoperations for flexor tendon pathology, or overall reoperations. Conclusions Pronator quadratus repair was more commonly performed in younger patients and in patients with a lower Soong grade. Hand-subspecialized surgeons are more likely to pursue PQ repair than trauma-subspecialized surgeons. This study did not detect statistically significant differences in hardware removal, flexor tendon pathology, or overall reoperations between groups.

Contains fulltext : 220936.pdf (Publisher’s version ) (Closed access) Introduction: Shoulder abnormalities on imaging are increasingly common with advancing age.We tested the difference in the accuracy of diagnosing the injured shoulder between surgeons who reviewed MRI reports and who did and did not receive information about the patients. METHODS: Thirty people aged 40 or older that experienced new shoulder symptoms after an event at work had MRI of both shoulders. Members of the Science of Variation Group (SOVG) were invited to review the radiologist's reports and diagnose the symptomatic side. Ninety-seven surgeons participated. RESULTS: Surgeon observers provided with patient information were not more accurate in diagnosing the symptomatic shoulder (Odds Ratio: 0.90; 95% CI: 0.75 to 1.1; P = 0.29). There was slight agreement between surgeons (kappa = 0.10). The sensitivity and specificity for diagnosing the symptomatic side were 51% (CI: 48%-54%) and 67% (CI: 64%-70%) respectively. A binomial test showed that surgeons indicated the injured shoulder slightly more frequently than expected by random chance (59%; P

Purpose The purpose of this study was to compare reintervention and perceived recurrence, with minimum 5 years of telephone follow-up, after limited fasciectomy or collagenase Clostridium histolyticum (CCH) in the treatment of Dupuytren contracture affecting a single digit. Methods We performed a retrospective cohort study of 48 patients with single digit treatment who underwent limited surgical fasciectomy at one hospital and 111 patients who underwent CCH treatment at a second hospital from 2010 to 2013. Patients were contacted by telephone about reintervention and perceived recurrence. Average length of telephone follow-up was 7.3 years in the CCH group and 7.4 years in the surgery group. The 2 groups were compared using 2 methods to control for potential confounding bias: (1) propensity score matching and (2) multivariable analysis accounting for potential confounders. Results After propensity score matching, there were 44 patients in each group with similar disease and demographic characteristics. Rates of reintervention and perceived recurrence were significantly higher in the CCH group than the surgery group at a minimum of 5 years following treatment. Conclusions Long-term overall reintervention and perceived recurrence following treatment of Dupuytren contracture affecting a single digit were higher with CCH treatment than surgical fasciectomy when comparing groups with similar baseline characteristics. Our findings may be used to counsel patients on the durability of the outcomes of treatment when considering treatment options for Dupuytren contractures. Type of study/level of evidence Therapeutic IV.

The aim of this study was to evaluate risk factors for symptomatic hardware and removal of hardware (ROH) after olecranon open reduction and internal fixation (ORIF) and to assess differences between olecranon locking plate and screws (P&S) or tension band (TB) wire cohorts. The medical records of 331 patients with olecranon fractures treated at two academic level I trauma centers with ORIF from 2012 to 2016 were reviewed. A total of 189 patients were included in the study. Complications, ROH, and subsequent surgery were assessed and compared between cohorts. There were 124 cases in the P&S cohort and 65 in the TB cohort. The overall reoperation rate was 31.2% (59 of 189). The overall incidence of ROH for all cases was 29.1% (55 of 189). Patients who required ROH or developed symptomatic hardware were significantly younger than those who did not (P&S, P P Orthopedics . 2020;43(3):141–146.]

BACKGROUND: Preliminary experience suggests that deep learning algorithms are nearly as good as humans in detecting common, displaced, and relatively obvious fractures (such as, distal radius or hip fractures). However, it is not known whether this also is true for subtle or relatively nondisplaced fractures that are often difficult to see on radiographs, such as scaphoid fractures. QUESTIONS/PURPOSES: (1) What is the diagnostic accuracy, sensitivity, and specificity of a deep learning algorithm in detecting radiographically visible and occult scaphoid fractures using four radiographic imaging views? (2) Does adding patient demographic (age and sex) information improve the diagnostic performance of the deep learning algorithm? (3) Are orthopaedic surgeons better at diagnostic accuracy, sensitivity, and specificity compared with deep learning? (4) What is the interobserver reliability among five human observers and between human consensus and deep learning algorithm? METHODS: We retrospectively searched the picture archiving and communication system (PACS) to identify 300 patients with a radiographic scaphoid series, until we had 150 fractures (127 visible on radiographs and 23 only visible on MRI) and 150 non-fractures with a corresponding CT or MRI as the reference standard for fracture diagnosis. At our institution, MRIs are usually ordered for patients with scaphoid tenderness and normal radiographs, and a CT with radiographically visible scaphoid fracture. We used a deep learning algorithm (a convolutional neural network [CNN]) for automated fracture detection on radiographs. Deep learning, an advanced subset of artificial intelligence, combines artificial neuronal layers to resemble a neuron cell. CNNs-essentially deep learning algorithms resembling interconnected neurons in the human brain-are most commonly used for image analysis. Area under the receiver operating characteristic curve (AUC) was used to evaluate the algorithm's diagnostic performance. An AUC of 1.0 would indicate perfect prediction, whereas 0.5 would indicate that a prediction is no better than a flip of a coin. The probability of a scaphoid fracture generated by the CNN, sex, and age were included in a multivariable logistic regression to determine whether this would improve the algorithm's diagnostic performance. Diagnostic performance characteristics (accuracy, sensitivity, and specificity) and reliability (kappa statistic) were calculated for the CNN and for the five orthopaedic surgeon observers in our study. RESULTS: The algorithm had an AUC of 0.77 (95% CI 0.66 to 0.85), 72% accuracy (95% CI 60% to 84%), 84% sensitivity (95% CI 0.74 to 0.94), and 60% specificity (95% CI 0.46 to 0.74). Adding age and sex did not improve diagnostic performance (AUC 0.81 [95% CI 0.73 to 0.89]). Orthopaedic surgeons had better specificity (0.93 [95% CI 0.93 to 0.99]; p < 0.01), while accuracy (84% [95% CI 81% to 88%]) and sensitivity (0.76 [95% CI 0.70 to 0.82]; p = 0.29) did not differ between the algorithm and human observers. Although the CNN was less specific in diagnosing relatively obvious fractures, it detected five of six occult scaphoid fractures that were missed by all human observers. The interobserver reliability among the five surgeons was substantial (Fleiss' kappa = 0.74 [95% CI 0.66 to 0.83]), but the reliability between the algorithm and human observers was only fair (Cohen's kappa = 0.34 [95% CI 0.17 to 0.50]). CONCLUSIONS: Initial experience with our deep learning algorithm suggests that it has trouble identifying scaphoid fractures that are obvious to human observers. Thirteen false positive suggestions were made by the CNN, which were correctly detected by the five surgeons. Research with larger datasets-preferably also including information from physical examination-or further algorithm refinement is merited. LEVEL OF EVIDENCE: Level III, diagnostic study.

Purpose This study sought to determine the impact of volar plate prominence on reoperation rates after open reduction and internal fixation of distal radius fractures with volar locking plates and to identify other factors associated with removal of hardware (ROH) or a reoperation. Methods A retrospective study of patients who underwent distal radius open reduction and internal fixation between 2012 and 2016 at 2 level I trauma centers was conducted. Plate prominence was evaluated using the Soong index at the first postoperative visit. The details of patient demographics, fracture and plate characteristics, complications, and reoperations were recorded. Bivariate and multivariable regression analyses were used to identify factors associated with increased rates of ROH and overall reoperation. Results A total of 732 (70.2%) of 1,042 patients completed follow-up at an average of 38.2 months, including 34 patients with bilateral operations, yielding 766 distal radius fractures. One hundred sixteen (15.1%) patients underwent reoperation at an average of 12.1 ± 13.6 months after the index surgery. Removal of hardware was the most commonly performed reoperation (77 patients, 10%). The multivariable regression analysis revealed significantly higher rates of ROH in Soong grade 1 or 2 patients (odds ratio 16, 95% CI 5.8–47; odds ratio 44, 95% CI 14–140, respectively) than in Soong grade 0 patients. Plate type, younger age, bilateral injuries, and concomitant procedures at the time of the index operation were all associated with increased risk of ROH. There were significant differences between individual surgeons the in rates of ROH (range 2.1%–22%) and overall reoperation (range 5.2%–36%). Compared with other hand surgeons, fellowship-trained hand surgeons had lower rates of ROH (8% vs 14%, respectively) and overall reoperation (12% vs 22%, respectively). Conclusions The rates of ROH and overall reoperation increase with increasing Soong grade. Plate type is independently predictive of future ROH. Older patients and those undergoing open reduction and internal fixation experience lower rates of subsequent reoperation. Type of study/level of evidence Prognostic IV.

Tumor resection followed by reconstruction with a proximal femoral endoprosthesis or an allograft-prosthesis composite are the two main alternatives for treatment of proximal femoral malignancies. This review describes the revision rate, implant survival, limb salvage rate, and function. Overall revision rates are high and reasons for failure differ between treatment modalities. Rate and reasons for amputation are comparable between both methods. Functional outcome was reasonable to good on average for both treatment modalities. Level of evidence: IV, systematic review and meta-analysis.

Background Previous studies have shown that venous thromboembolism (VTE) is a complication associated with neoplastic disease and major orthopaedic surgery. However, many potential risk factors remain undefined. Questions/purposes (1) What proportion of patients develop symptomatic VTE after surgery for long bone metastases? (2) What factors are associated with the development of symptomatic VTE among patients receiving surgery for long bone metastases? (3) Is there an association between the development of symptomatic VTE and 1-year survival among patients undergoing surgery for long bone metastases? (4) Does chemoprophylaxis increase the risk of wound complications among patients undergoing surgery for long bone metastases? Methods A retrospective study identified 682 patients undergoing surgical treatment of long bone metastases between 2002 and 2013 at the Massachusetts General Hospital and Brigham and Women's Hospital. We included patients 18 years of age or older who had a surgical procedure for impending or pathologic metastatic long bone fracture. We considered the humerus, radius, ulna, femur, tibia, and fibula as long bones; metastatic disease was defined as metastases from solid organs, multiple myeloma, or lymphoma. In general, we used 40 mg enoxaparin daily for lower extremity surgery and 325 mg aspirin daily for lower or upper extremity surgery. The primary outcome was a VTE defined as any symptomatic pulmonary embolism (PE) or symptomatic deep vein thrombosis (DVT; proximal and distal) within 90 days of surgery as determined by chart review. The tertiary outcome was defined as any documented wound complication that might be attributable to chemoprophylaxis within 90 days of surgery. At followup after 90 days and 1 year, respectively, 4% (25 of 682) and 8% (53 of 682) were lost to followup. Statistical analysis was performed using multivariable logistic and Cox regression and Kaplan-Meier. Results Overall, 6% (44 of 682) of patients had symptomatic VTE; 22 patients sustained a DVT, and 22 developed a PE. After controlling for relevant confounding variables, higher preoperative hemoglobin level was independently associated (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.60-0.93; p = 0.011) with decreased symptomatic VTE risk, the presence of symptomatic VTE was associated with a worse 1-year survival rate (VTE: 27% [95% CI, 14%-40%] and non-VTE: 39% [95% CI, 35%-43%]; p = 0.041), and no association was found between wound complications and the use of chemoprophylaxis (OR, 3.29; 95% CI, 0.43-25.17; p = 0.252). Conclusions The risk of symptomatic 90-day VTE is high in patients undergoing surgery for long bone metastases. Further study would be needed to determine the VTE prevention strategy that best balances risks and benefits to address this complication. Level of evidence Level III, therapeutic study.

Purposes: The primary objective of this study is to compare the likelihood of acute compartment syndrome in the leg versus the forearm in patients who undergo fasciotomy for a clinical diagnosis of suspected acute compartment syndrome. The secondary objective is to identify factors associated with higher likelihood of acute compartment syndrome or with the use of split-thickness skin graft in these patients. Methods: We identified 449 patients diagnosed with suspected acute compartment syndrome of 468 legs and 119 patients diagnosed with suspected acute compartment syndrome of 119 forearms, treated with fasciotomy, from January 2000 to June 2015. Patients clinically diagnosed with suspected acute compartment syndrome were scored for likelihood of acute compartment syndrome based on muscle appearance, time to closure, neurologic deficit at final follow-up, and contracture at final follow-up. Results: There was no difference in likelihood of acute compartment syndrome between the leg and the forearm, with about 70% having relatively high likelihood. Forearm fasciotomy was associated with documentation of poorer muscle appearance (p = 0.01) and contracture (p < 0.001) compared with leg fasciotomy. Multivariable logistic regression analyses showed that compartment pressure measurement (p = 0.01) was associated with higher likelihood of acute compartment syndrome in legs and that male sex (p = 0.001) and non-vascular mechanism of injury (p = 0.02) were associated with split-thickness skin graft in legs. Conclusions: The likelihood and severity of acute compartment syndrome are comparable in the leg and the forearm.

STUDY DESIGN This was a retrospective cohort study from 2 affiliated tertiary care referral centers for spine disease. OBJECTIVE The purpose of this article was to assess the prevalence of incidental (ie, asymptomatic) and symptomatic lumbar synovial facet cysts on magnetic resonance imaging. Secondarily, we assessed whether the prevalence increases with age. In addition, we assessed differences in patient and cyst characteristics between asymptomatic and symptomatic facet cysts. SUMMARY OF BACKGROUND The prevalence of symptomatic and asymptomatic synovial facet cysts in the lumbar spine has been incompletely established, and, although many studies demonstrate an association with degenerative spine disease, no cumulative increase in prevalence of synovial facet cysts with increasing age has been presented. METHODS We included 19,010 consecutive patients who underwent a dedicated lumbar spine magnetic resonance imaging between 2004 and 2015. Our outcome measures were symptomatic and asymptomatic facet cysts. A symptomatic cyst was defined as a cyst with symptoms of radiculopathy on the same side as the cyst. RESULTS The overall synovial facet cyst prevalence was 6.5% [95% confidence interval (CI), 6.1-6.8]; 46% of the facet cysts were incidental and 54% were symptomatic. Increased age was independently associated with a higher likelihood of having a synovial facet cyst [odds ratio (per 10 y), 1.24, 95% CI, 1.20-1.29; P

Background We assessed whether there was a difference in attenuation measurements (in Hounsfield units – HU) and geometric distribution of HU between femora with metastatic lesions that fracture, and metastatic lesions that did not fracture nor underwent prophylactic fixation. Methods Nine patients with femoral metastases who underwent CT and developed a pathological fracture were matched to controls. All femora were delineated in axial CT slices using a region of interest (ROI) tool; the HU within these ROIs were used to calculate: (1) the cumulative HU of the affected over the nonaffected side per slice and presented as a percentage, and (2) the cumulative HU accounting for geometric distribution (polar moment of HU). We repeated the analyses including cortical bone only (HU of 600 and above). Results CT-based calculations did not differ between patients with a lesion that fractured and those that did not fracture nor underwent prophylactic fixation when analyzing all tissue. However, when including cortical bone only, the pathological fracture group had a lower cumulative HU value compared to the no fracture and no fixation group for the weakest cross-sectional CT image (pathological fracture group, mean: 71, SD: 23 and no fracture and no prophylactic fixation group, mean: 85, SD: 18, p = 0.042) and the complete lesion analysis (pathological fracture group, mean: 78, SD: 21 and no fracture and no prophylactic fixation group, mean: 92, SD: 15, p = 0.032). Conclusion The demonstrated CT-based algorithms can be useful for predicting pathological fractures in metastatic lesions.

Background: Wrist pain is often nonspecific. Magnetic resonance imaging (MRI) is regularly obtained to evaluate wrist pain. Variations and pathophysiology identified on MRI may not account for patient’s clinical symptoms. This study aims to quantify the prevalence of flexor carpi radialis (FCR) tendinopathy on MRI and the coexistence of trapeziometacarpal (TMC) or scaphotrapeziotrapezoid (STT) osteoarthritis. Methods: Using an institutional research database, we identified 3631 adult patients who obtained an MRI of the wrist during a 15-year period. Text search in the radiology reports identified 302 patients with possible FCR signal abnormalities. After reviewing the medical records, 98 patients were identified with FCR tendinopathy. Furthermore, medical records were used to identify pain located on the volar radial part of the wrist. In the absence of a documented examination consistent with FCR tendinopathy, we considered any signal change in the FCR incidental. Results: We identified 55 patients (55%) with incidental FCR tendinopathy. In a bivariate analysis, we found FCR signal changes on the MRI were associated with older age, white race, clinically suspected FCR tendinopathy, volar-radial sided wrist pain, and TMC and STT arthritis. Using multivariable logistic regression to account for confounding, older age and volar-radial sided wrist pain were independently associated with FCR signal changes on MRI. Conclusions: Signal changes in the FCR are infrequent and often incidental (asymptomatic) or associated with peritrapezial osteoarthritis.

This is a retrospective study.To compare (1) recurrence of radiculopathy and (2) back pain after decompression with and without fusion for patients with a symptomatic synovial cyst.Previous work described favorable outcomes following cyst excision with and without fusion. Because of the association of facet cysts with spinal instability it is hypothesized that a decompression with fusion will lead to better outcomes. However, previous studies present contradicting results.We included 314 consecutive patients that underwent operative treatment for a facet cyst between 2003 and 2013 at 2 tertiary spine referral centers: 224 (71%) underwent decompression without fusion (35% spondylolisthesis), 90 (29%) underwent decompression with fusion (63% spondylolisthesis). Baseline data were compared between the groups. Bivariate log-rank analysis was used to compare outcomes between groups, followed by multivariable Cox regression analysis accounting for differences in baseline characteristics.Patients undergoing decompression with fusion presented with a higher incidence of back pain (P=0.004) and spondylolisthesis (P0.001), had more often bilateral decompressions (P0.001), more facetectomies (P0.001), and more levels of decompression (P=0.004) than those who underwent decompression alone. We found a difference in recurrence of radiculopathy (no fusion: 25% vs. fusion: 9.4%, P=0.029) in bivariate analysis. However, this difference did not hold when accounting for confounders (hazard ratio, 0.50, 95% confidence interval, 0.19-1.31, P=0.16). There was no difference in recurrence of back pain in bivariate (no fusion: 29% vs. fusion: 22%, P=0.51) and multivariable analysis (hazard ratio 0.51, 95% confidence interval, 0.23-1.14, P=0.10).We found, with the numbers evaluated, no difference in recurrence of radiculopathy or back pain between patients undergoing decompression with or without fusion after accounting for confounders. The decision for fusion should be considered in light of the extent of decompression and the existence of other pathology.Level III-therapeutic study.

Spinal epidural lipomatosis (SEL) refers to an excessive accumulation of fat within the epidural space. It can be idiopathic or secondary, resulting in significant morbidity. The prevalence of SEL, including idiopathic and secondary SEL, and its respective risk factors are poorly defined.We sought to: (1) assess the prevalence of SEL among patients who underwent a dedicated magnetic resonance imaging (MRI) scan of the spine-including incidental SEL (ie, SEL without any spine-related symptoms), SEL with spine-related symptoms, and symptomatic SEL (ie, with symptoms specific for SEL); and (2) assess factors associated with overall SEL and subgroups. In addition, we assessed differences between SEL subgroups.We reviewed the records of 28,902 patients, aged 18 years and older with a spine MRI (2004 to 2015) at two tertiary care centers. We identified SEL cases by searching radiology reports for SEL, including synonyms and misspellings. Prevalence numbers were calculated as a percentage of the total number of patients. We used multivariate logistic regression analysis to identify factors associated with overall SEL and subgroups.The prevalence of overall SEL was 2.5% (731 of 28,902): incidental SEL, 0.6% (168 of 28,902); SEL with symptoms, 1.8% (526 of 28,902); and symptomatic SEL, 0.1% (37 of 28,902). Factors associated with overall SEL in multivariate analysis were the following: older age (odds ratio [OR]: 1.01, 95% confidence interval [CI]: 1.01-1.02, p.001), higher modified Charlson comorbidity index (OR: 1.10, 95% CI: 1.07-1.13, p.001), male sex (OR: 2.01, 95% CI: 1.71-2.37, p.001), BMI30 (OR: 2.59, 95% CI: 1.97-3.41, p.001), Black/African American race (OR: 1.66, 95% CI: 1.24-2.23, p=.001), systemic corticosteroid use (OR: 2.59, 95% CI: 1.69-3.99, p.001), and epidural corticosteroid injections (OR: 3.48, 95% CI: 2.82-4.30, p.001).We found that about 1 in 40 patients undergoing a spine MRI had SEL; 23% of whom with no symptoms, 72% with spine-related symptoms, and 5% with symptoms specific for SEL. Our data help identify patients who might warrant an increased index of suspicion for SEL.

The United States and Canada are in the midst of an epidemic of the use, misuse and overdose of opioids, and deaths related to overdose. This is the direct result of overstatement of the benefits and understatement of the risks of using opioids by advocates and pharmaceutical companies. Massive amounts of prescription opioids entered the community and were often diverted and misused. Most other parts of the world achieve comparable pain relief using fewer opioids. The misconceptions about opioids that created this epidemic are finding their way around the world. There is particular evidence of the increased prescription of strong opioids in Europe. Opioids are addictive and dangerous. Evidence is mounting that the best pain relief is obtained through resilience. Opioids are often prescribed when treatments to increase resilience would be more effective. Cite this article: Bone Joint J 2017;99-B:856–64.

General questionnaires are often used to assess quality of life in patients with spine metastases, although a disease-specific survey did not exist until recently. The Spine Oncology Study Group has developed an outcomes questionnaire (SOSG-OQ) to measure quality of life in these patients. However, a scoring system was not developed, and the questionnaire was not validated in a group of patients, nor was it compared with other general quality of life questionnaires such as the EuroQol 5 Dimensions (EQ-5D) questionnaire.Our primary null hypothesis is that there is no association between the SOSG-OQ and EQ-5D. Our secondary null hypothesis is that there is no difference in coverage and internal consistency between the SOSG-OQ and EQ-5D. We also assess coverage, consistency, and validity of the domains within the SOSG-OQ.A survey study from a tertiary care spine referral center was used for this study.The patient sample consisted of 82 patients with spine metastases, myeloma, or lymphoma.The SOSG-OQ (27 questions, 6 domains) score ranges from 0 to 80, with a higher score indicating worse quality of life. The EQ-5D (5 questions, 5 domains) index score ranges from 0 to 1, with a higher score indicating better quality of life.The association between the SOSG-OQ and EQ-5D index score was assessed using the Spearman rank correlation. Instrument coverage and precision were assessed by determining item completion rate, median score with range, and floor and ceiling effect. Internal consistency was assessed using Cronbach alpha. Multitrait analysis and exploratory factor analysis were used to analyze properties of the individual domains in the SOSG-OQ.The Spearman rank correlation between the SOSG-OQ and EQ-5D questionnaire was high (r=-0.83, p.001). Internal consistency of the SOSG-OQ (0.92, 95% CI: 0.89-0.94) was higher as compared to the internal consistency of the EQ-5D (0.73, 95% CI: 0.63-0.84; p.001). The SOSG-OQ score had no floor or ceiling effect indicating good coverage (median 30, range 3-64), whereas the EQ-5D had a ceiling effect of 10% (median 0.71, range 0.05-1).In conclusion, our study proposes a scoring methodology-after reversing four inversely scored items-for the SOSG-OQ and shows that the questionnaire is a valid tool for the assessment of quality of life in patients with metastatic spine disease. The SOSG-OQ is superior to the EQ-5D in terms of coverage and internal consistency but consists of more questions.

Background Context Patient-reported outcomes are becoming increasingly important when investigating results of patient and disease management. In sacral tumor, the symptoms of patients can vary substantially; therefore, no single questionnaire can adequately account for the full spectrum of symptoms and disability. Purpose The purpose of this study is to analyze redundancy within the current sacral tumor survey and make a recommendation for an updated version based on the results and patient and expert opinions. Study Design/Setting A survey study from a tertiary care orthopedic oncology referral center was used. Patient Sample The patient sample included 70 patients with sacral tumors (78% chordoma). Outcome Measures The following 10 questionnaires included in the current sacral tumor survey were evaluated: the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Item short form, PROMIS Pain Intensity short form, PROMIS Pain Interference short form, PROMIS Neuro-QOL v1.0 Lower Extremity Function short form, PROMIS v1.0 Anxiety short form, the PROMIS v1.0 Depression short form, the International Continence Society Male short form, the Modified Obstruction-Defecation Syndrome questionnaire, the PROMIS Sexual Function Profile v1.0, and the Stoma Quality of Life tool. Methods We performed an exploratory factor analysis to calculate the possible underlying latent traits. Spearman rank correlation coefficients were used to measure to what extent the questionnaires converged. We hypothesized the existence of six domains based on current literature: mental health, physical health, pain, gastrointestinal symptoms, sexual function, and urinary incontinence. To assess content validity, we surveyed 32 patients, 9 orthopedic oncologists, 1 medical oncologist, 1 radiation oncologist, and 1 orthopedic oncology nurse practitioner with experience in treating sacral tumor patients on the relevance of the domains. Results Reliability as measured by Cronbach alpha ranged from 0.65 to 0.96. Coverage measured by floor and ceiling effects ranged from 0% to 52% and from 0% to 30%, respectively. Explanatory factor analysis identified three traits to which the questionnaires that were expected to measure a similar construct correlated the most: mental health, physical function, and pain. Content validity index demonstrated low disagreement among patients (range: 0.10–0.18) and high agreement among physicians (range: 0.91–1.0) on the relevance of the proposed domains. Social health was identified by 50% of the commenting patients as an important yet missing domain. Conclusions The current sacral tumor survey is incomplete and time-consuming, and not all surveys are appropriate for the sacral tumor population. Our recommended survey contains less than half the questions and includes the newly recognized social health domain.

It would be helpful for the decision-making process of patients with metastatic bone disease to understand which patients are at risk for worse quality of life (QOL), pain, anxiety, and depression. Normative data, and where these stand compared with general population scores, can be useful to compare and interpret results of similar patients or patient groups, but to our knowledge, there are no such robust data. We wished (1) to assess what factors are independently associated with QOL, pain interference, anxiety, and depression in patients with metastatic bone disease, and (2) to compare these outcomes with general US population values. Between November 2011 and February 2015, 859 patients with metastatic bone disease presented to our orthopaedic oncology clinic; 202 (24%) were included as they completed the EuroQOL-5 Dimension (EQ-5D(TM)), PROMIS(®) Pain Interference, PROMIS(®) Anxiety, and PROMIS(®) Depression questionnaires as part of a quality improvement program. We did not record reasons for not responding and found no differences between survey respondents and nonrespondents in terms of age (63 versus 64 years; p = 0.916), gender (51% men versus 47% men; p = 0.228), and race (91% white versus 88% white; p = 0.306), but survey responders were more likely to be married or living with a partner (72%, versus 62%; p = 0.001). We assessed risk factors for QOL, pain interference, anxiety, and depression using multivariable linear regression analysis. We used the one-sample signed rank test to assess whether scores differed from US population averages drawn from earlier large epidemiologic studies. Younger age (β regression coefficient [β], < 0.01; 95% CI, 0.00-0.01; p = 0.041), smoking (β, -0.12; 95% CI, -0.22 to -0.01; p = 0.026), pathologic fracture (β, -0.10; 95% CI, -0.18 to -0.02; p = 0.012), and being unemployed (β, -0.09; 95% CI, -0.17 to -0.02; p = 0.017) were associated with worse QOL. Current smoking status was associated with more pain interference (β, 6.0; 95% CI, 1.6-11; p = 0.008). Poor-prognosis cancers (β, 3.8; 95% CI, 0.37-7.2; p = 0.030), and pathologic fracture (β, 6.3; 95% CI, 2.5-7.2; p = 0.001) were associated with more anxiety. Being single (β, 5.9; 95% CI, 0.83-11; p = 0.023), and pathologic fracture (β, 4.4; 95% CI, 0.8-8.0; p = 0.017) were associated with depression. QOL scores (0.68 versus 0.85; p < 0.001), pain interference scores (65 versus 50; p < 0.001), and anxiety scores (53 versus 50; p = 0.011) were worse for patients with bone metastases compared with general US population values, whereas depression scores were comparable (48 versus 50; p = 0.171). Impending pathologic fractures should be treated promptly to prevent deterioration in QOL, anxiety, and depression. Our normative data can be used to compare and interpret results of similar patients or patient groups. Future studies could focus on specific cancers metastasizing to the bone, to further understand which patients are at risk for worse patient-reported outcomes. Level III, prognostic study

Study Design: Retrospective cohort study. Objectives: (1) To assess patient-reported outcomes—physical function, pain, and quality of life—in patients who underwent resection of a mobile spine chondrosarcoma. (2) To assess complications (90 days), readmissions, reoperations, oncological outcomes, and neurologic status. Methods: Thirty-three patients with spinal conventional chondrosarcoma resection between 1984 and 2014 at one hospital were included. The primary outcome measures were—minimally 6 months after surgery—the EuroQol 5 Dimensions (EQ5D), PROMIS–Physical Function, PROMIS–Pain Intensity, and Oswestry (ODI) Disability Index, or Neck (NDI) Disability established in 14 out of 20 alive (70.0%) patients. Complications, readmission, reoperations, oncological outcomes, and neurological status were reported for the complete cohort of 33 patients. Results: After spine chondrosarcoma resection, patients (n = 14) reported worse physical function (median 43, range 22-61, P = .026), worse quality of life (median EQ5D 0.70, range 0.04-1, P = .022), and comparable pain intensity (median 47, range 31-56, P = .362) when compared with US general population values. The median NDI/ODI was 25 (range 0-72) indicating mild to moderate disability. Patients undergoing reoperation had worse patient-reported outcomes than those who did not. Eighteen (55.5%) out of 33 patients suffered complications (90 days), 14 (42.4%) had unplanned readmission, and 13 (39.4%) underwent reoperation. Intralesional resection was associated with increased readmission, reoperation, and recurrence rate. Conclusions: Chondrosarcoma affects quality of life and physical function and its treatment frequently results in complications and reoperations. Our findings can be used to inform future patients about expected outcomes.

BACKGROUND: Artificial-intelligence algorithms derive rules and patterns from large amounts of data to calculate the probabilities of various outcomes using new sets of similar data. In medicine, artificial intelligence (AI) has been applied primarily to image-recognition diagnostic tasks and evaluating the probabilities of particular outcomes after treatment. However, the performance and limitations of AI in the automated detection and classification of fractures has not been examined comprehensively. QUESTION/PURPOSES: In this systematic review, we asked (1) What is the proportion of correctly detected or classified fractures and the area under the receiving operating characteristic (AUC) curve of AI fracture detection and classification models? (2) What is the performance of AI in this setting compared with the performance of human examiners? METHODS: The PubMed, Embase, and Cochrane databases were systematically searched from the start of each respective database until September 6, 2018, using terms related to “fracture”, “artificial intelligence”, and “detection, prediction, or evaluation.” Of 1221 identified studies, we retained 10 studies: eight studies involved fracture detection (ankle, hand, hip, spine, wrist, and ulna), one addressed fracture classification (diaphyseal femur), and one addressed both fracture detection and classification (proximal humerus). We registered the review before data collection (PROSPERO: CRD42018110167) and used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). We reported the range of the accuracy and AUC for the performance of the predicted fracture detection and/or classification task. An AUC of 1.0 would indicate perfect prediction, whereas 0.5 would indicate a prediction is no better than a flip-of-a-coin. We conducted quality assessment using a seven-item checklist based on a modified methodologic index for nonrandomized studies instrument (MINORS). RESULTS: For fracture detection, the AUC in five studies reflected near perfect prediction (range, 0.95-1.0), and the accuracy in seven studies ranged from 83% to 98%. For fracture classification, the AUC was 0.94 in one study, and the accuracy in two studies ranged from 77% to 90%. In two studies AI outperformed human examiners for detecting and classifying hip and proximal humerus fractures, and one study showed equivalent performance for detecting wrist, hand and ankle fractures. CONCLUSIONS: Preliminary experience with fracture detection and classification using AI shows promising performance. AI may enhance processing and communicating probabilistic tasks in medicine, including orthopaedic surgery. At present, inadequate reference standard assignments to train and test AI is the biggest hurdle before integration into clinical workflow. The next step will be to apply AI to more challenging diagnostic and therapeutic scenarios when there is absence of certitude. Future studies should also seek to address legal regulation and better determine feasibility of implementation in clinical practice. LEVEL OF EVIDENCE: Level II, diagnostic study.

The primary aim of this paper is to introduce Quantitative 3-dimensional Computed Tomography (Q3DCT) for odontoid fractures to assess if fracture characteristics differ between the Anderson and d'Alonso subclasses. Secondarily, we assessed if high energy injury and older age influenced fracture morphology. This retrospective imaging study includes 66 patients who visited one of two level I trauma centers for an odontoid fracture. With the use of 3-Dimensional polygon mesh models we determined the total number of fragments, the volume of each fragment, the degree of displacement of the odontoid, and the fracture surface area. We found that type III fractures consisted of more fracture fragments (median:3, IQR:2–3) than type II odontoid fractures (median:2, IQR:2–3) (p < 0.001). The volume of the odontoid fracture fragment was almost twice as large in type III odontoid fractures (median:19%, IQR:14–25%) as compared to type II fractures (median:10%, IQR:8.5–12%) (p < 0.001). Type II fractures were more displaced (median:3.8 mm, IQR:2.9–6.3 mm) compared to type III fractures (median:2.2 mm, IQR:1.0–3.5 mm) (p < 0.001). This 3-dimensional displacement was predominantly due to substantially more posterior displacement of type II odontoid fractures. In conclusion, type III odontoid fractures were more comminuted, had a larger odontoid fragment, had a larger fracture surface, but were less (posteriorly) displaced when compared to type II fractures. The mechanism of injury and age at diagnosis both dictated the fracture type, but when accounting for fracture type the influence of these two factors on fracture morphology was limited.

Purpose Operative treatment of trapeziometacarpal osteoarthritis (TMC OA) is discretionary. There is substantial surgeon-to-surgeon variation in offers of surgery. This study assessed factors associated with variation in recommendation of operative treatment to patients with TMC OA. Secondarily, we studied factors associated with preferred operative technique and surgeon demographic factors variability in recommendation for operative treatment. Methods We invited all hand surgeon members of the Science of Variation Group to review 16 scenarios of patients with TMC OA and asked the surgeons whether they would recommend surgical treatment for each patient and, if yes, which surgical technique they would offer (trapeziectomy, trapeziectomy with ligament reconstruction and/or tendon interposition, joint replacement, or arthrodesis). Scenarios varied in pain intensity, relief after injection, radiographic severity, and psychosocial symptoms. Results Patient characteristics associated with greater likelihood to recommend surgical treatment were substantial pain, a previous injection that did not relieve pain, radiograph with severe TMC OA, and few symptoms of depression. Practice region was the only factor associated with preferred surgical technique and trapeziectomy with ligament reconstruction and/or tendon interposition the most commonly recommended treatment. There was low agreement among surgeons regarding treatment recommendations. Conclusions The notable variation in offers of operative treatment for TMC OA is largely associated with variable attention to subjective factors. Future studies might address the relative influence of surgeon incentives and beliefs, objective pathophysiology, and subjective patient factors on variation in surgeon recommendations. Clinical relevance Surgeons’ awareness of the potential influence of subjective factors on their recommendations might contribute to efforts to ensure that patient choices reflect what matters most to them and are not based on misconceptions.

Purpose We sought to determine and quantify which subspecialties of orthopedic surgeons are operating off hours in an urban, quaternary-care, level 1 trauma center. Materials and methods We used our clinical registry to identify 43,211 orthopedic surgeries performed between January 2008 and December 2011. Our outcome measures were the number and proportion of off-hour surgeries performed as well as the number and proportion of off-hours per subspecialty. The denominators were the total number of surgeries and the total number of surgical hours worked per subspecialty. Subspecialties—based on the primary surgeon who performed the surgery—were arthroplasty, foot and ankle, hand, pediatrics, shoulder, spine, sports, orthopedic trauma, and orthopedic oncology. Results A total of 2,431 (5.6%) surgeries were off-hours; the overall ratio of off-hour to on-hour surgeries was 1 to 17. There was a difference in the proportion of off-hour surgeries performed among orthopedic subspecialties: trauma (ratio, 1:5) and pediatric specialists (ratio, 1:5) had the lowest ratio, and shoulder (ratio, 1:152) and sports (ratio, 1:98) specialists the highest. The total number of surgical hours among all specialties was 59,026; of these hours, 3,833 (6.5%) were off-hour. The ratio of off-hour to on-hour surgical hours was 1 to 14. There was a difference in proportion of hours worked off-hour among orthopedic subspecialties; the ratios were greatest for trauma (1:5) and hand (1:5) specialists and the least for shoulder (1:157) and sports (1:92) specialists. Seven percent of hand surgery cases were off-hour, and 16% of the total surgical hours worked by hand surgeons were off-hour. Conclusions In an urban, academic, level 1 trauma and microvascular replantation regional referral hospital, there is a large difference in off-hour surgical volume and duration among orthopedic subspecialties: trauma, pediatric, and hand surgeons performed more off-hour work than their colleagues, with hand and pediatric surgeons the most likely to be working at night. Clinical relevance These data can inform how we organize, value, and incentivize off-hour care.

Background and Objectives We assessed whether allogeneic blood transfusions were associated with infection—within 90 days—after surgery for bone metastatic disease. Furthermore, we assessed other risk factors associated with infection. Methods We included 1,266 patients surgically treated for a bone metastasis at two hospitals between 2002 and 2013. Blood transfusions within 7 days before and after surgery were considered perioperative. Results We found no independent association between exposure to blood transfusion and infection (odds ratio [OR] 1.02, 95% confidence interval [CI]: 0.76–1.37, P = 0.889), nor a dose–response relationship (OR 1.02, 95%CI: 0.98–1.07, P = 0.245). Older age (OR 1.01, 95%CI: 1.00–1.02, P = 0.035), a higher modified Charlson comorbidity index (OR 1.13, 95%CI: 1.05–1.22, P = 0.002), surgery to the axial skeleton (OR 1.89, 95%CI: 1.42–2.51, P

Study design Retrospective study. Objective To assess the relation between exposure to epidural steroid injection (ESI) before surgery and occurrence of surgical site infection (SSI) for degenerative lumbar spine conditions. Summary of background data The effect of local ESI on the occurrence of SSI is controversial. Methods Patients who underwent surgery for degenerative lumbar spine conditions at two centers between 2005 and 2015 were identified. Primary outcome measure was SSI within 90 days requiring surgical intervention. Results A total of 5311 patients (age 57 ± 16 years) were analyzed of which 945 (18%) had at least one ESI within 90 days of surgery. One hundred thirty-four (2.5%) patients developed an SSI requiring reoperation. No association of exposure or dose-response relationship was identified between ESI and SSI for any of the time periods (90-, 30-, and 30-90-day). Five (1.7%) of the 290 patients who had at least one ESI within 30 days before surgery had a postoperative infection compared to 129 (2.6%) of the 5021 in the non-ESI group (unadjusted odds ratio: 0.67, 95% CI: 0.27-1.64, P = 0.376). Fifteen (2.0%) of the 761 patients who had at least one ESI within 30 to 90 days before surgery had a postoperative infection, compared to 119 (2.6%) of the 4550 in the non-ESI group (unadjusted odds ratio: 0.75, 95% CI: 0.44-1.29, P = 0.296). Conclusion In this retrospective study we investigated whether an ESI and its timing influences the postoperative risk of an SSI. We found no association-exposure or dose-response relationship-between ESI and postoperative infection, even after adjusting for potential confounders, for any of the time periods (90-, 30-, and 30-90-day ESI). In addition, we did find that longer hospital stay, greater EBL, posterior approach, and drain placement were associated with higher infection rates. Level of evidence 3.

Objectives To assess, (i) the degree to which the: PROMIS Physical Function Cancer, PROMIS Neuro-QoL Mobility, Toronto Extremity Salvage Score (TESS), Lower Extremity Function Score (LEFS), and Musculoskeletal Tumor Society score (MSTS), measure physical function; (ii) differences in coverage and reliability; and (iii) difference in completion time. Methods One hundred of 115 (87%) patients with lower extremity metastases participated in this prospective study. We used exploratory factor analysis—correlating questionnaires with an underlying trait—to assess if questionnaires measure the same. Coverage was assessed by floor and ceiling effect and reliability by the standard error of measurement (SEM). Completion time was compared using the Friedman test. Results All questionnaires measured the same concept; demonstrated by high correlations (>0.7). Floor effect was absent, while ceiling effect was present in all, but highest for the PROMIS Neuro-QoL Mobility (7%). The SEM was below the threshold—indicating reliability—over a wide range of ability levels for the PROMIS-Physical Function, TESS, and LEFS. Completion time differed between questionnaires (P