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1. Predicting deep infection in pilon and tibial plateau fractures: a secondary analysis of the VANCO and OXYGEN trials

Author

Archie L. Overmann, MD, Anthony R. Carlini, MS, Robert V. O'Toole, MD, Renan C. Castillo, PhD, Nathan N. O'Hara, PhD, MHA, METRC, Eben A. Carroll, MD, James Brett Goodman, MBA, Martha B. Holden, AAS, AA, Anna N. Miller, MD, Amanda Spraggs-Hughes, PhD, Michael L. Brennan, MD, Paul Tornetta, III, MD, Patrick M. Osborn, MD, Jessica C. Rivera, MD, PhD, Clinton K. Murray, MD, Joseph E. Kimmel, MS, Michael J. Bosse, MD, Joseph R. Hsu, MD, Madhav A. Karunakar, MD, Laurence B. Kempton, MD, Rachel B. Seymour, PhD, Stephen H. Sims, MD, Christine Churchill, MA, Debra L. Sietsema, PhD, RN, Ida Leah Gitajn, MD, MS, Rachel M. Reilly, MD, Robert D. Zura, MD, Cameron Howes, BA, Hassan Mir, MD, MBA, Michael J. Weaver, MD, Marilyn Heng, MD, MPH, Thuan V. Ly, MD, Emily A. Wagstrom, MD, Jerald R. Westberg, MPH, BA, Brian H. Mullis, MD, Jeffrey O. Anglen, MD, Leilani S. Mullis, MD, Karl D. Shively, MD, Todd O. McKinley, MD, Roman M. Natoli, MD, PhD, Anthony Sorkin, MD, Lauren C. Hill, BS, CCRC, Robert A. Hymes, MD, Greg E. Gaski, MD, A. Stephen Malekzadeh, MD, Lolita Ramsey, PhD, RN, Jeff E. Schulman, MD, Cary C. Schwartzbach, MD, Robert A. Sikorski, MD, Olivia C. Lee, MD, Peter C. Krause, MD, Joshua L. Gary, MD, Timothy S. Achor, MD, Andrew Choo, MD, John W. Munz, MD, Sterling J. Boutte, BS, Matthew C. Galpin, CCRC, H. Michael Frisch, MD, Adam M. Kaufman, MD, C. Michael LeCroy, MD, Christopher S. Smith, MD, Alec C. Stall, MD, MPH, Andrea Horne, MA, CCRP, Manjari Joshi, MBBS, Jason W. Nascone, MD, Marcus F. Sciadini, MD, Gerard P. Slobogean, MD, Andrea L. Howe, BS, Roman Hayda, MD, Andrew R. Evans, MD, Stanislaw P. Stawicki, MD, MBA, Thomas R. Wojda, MD, MBA, Michael J. Gardner, MD, Julius A. Bishop, MD, Saqib Rehman, MD, MBA, Cyrus Caroom, MD, Elizabeth Sheridan, MPH, MACPR, Theodore Miclau, MD, Saam Morshed, MD, PhD, Thomas F. Higgins, MD, Justin M. Haller, MD, Clay A. Spitler, MD, Massimo Max Morandi, MD, FACS, Paul Edward Matuszewski, MD, Arun Aneja, MD, PhD, Patrick F. Bergin, MD, Eldrin Bhanat, MD, MPH, Matt L. Graves, MD, John Morellato, MBBS Hons, David Teague, MD, William Ertl, MD, Jaimo Ahn, MD, PhD, Gele B. Moloney, MD, John C. Weinlein, MD, Boris A. Zelle, MD, Animesh Agarwal, MD, Ravi A. Karia, MD, Ashoke Sathy, MD, Drew Sanders, MD, MPH, David B. Weiss, MD, Seth R. Yarboro, MD, Veronica Lester-Ballard, MSN, Eric D. McVey, MEd, CCRP, Reza Firoozabadi, MD, MA, Arman Dagal, MD, FRCA, Conor P. Kleweno, MD, Julie Agel, MA, Paul S. Whiting, MD, Natasha M. Simske, BS, Alexander B. Siy, BS, William T. Obremskey, MD, MPH, Basem Attum, MD, Eduardo J. Burgos, MD, Vamshi Gajari, MBBS, A. Alex Jahangir, MD, Andres Rodriguez-Buitrago, MD, Manish Sethi, MD, Daniel J. Stinner, MD, PhD, Rajesh R. Tummuru, MBBS, MBA, Karen M. Trochez, MA, BS, Jean-Claude G. D'Alleyrand, MD, MSE, Lauren E. Allen, DrPH, Susan C. Collins, MSc, Yanjie Huang, ScM, and Tara J. Taylor, MPH

Subjects
Orthopedic surgery, RD701-811
Abstract

Abstract. Objectives:. To develop and validate a prediction model for a deep surgical site infection (SSI) after fixation of a tibial plateau or pilon fracture. Design:. Pooled data from 2 randomized trials (VANCO and OXYGEN). Setting:. Fifty-two US trauma centers. Patients:. In total, 1847 adult patients with operatively treated tibial plateau or pilon fractures who met criteria for a high risk of infection. Intervention:. We considered 13 baseline patient characteristics and developed and externally validated prediction models using 3 approaches (logistic regression, stepwise elimination, and machine learning). Main Outcomes and Measures:. The primary prediction model outcome was a deep SSI requiring operative debridement within 182 days of definitive fixation. Our primary prognostic performance metric for evaluating the models was area under the receiver operating characteristic curve (AUC) with clinical utility set at 0.7. Results:. Deep SSI occurred in 75 VANCO patients (8%) and in 56 OXYGEN patients (6%). The machine learning model for VANCO (AUC = 0.65) and stepwise elimination model for OXYGEN (AUC = 0.62) had the highest internal validation AUCs. However, none of the external validation AUCs exceeded 0.64 (range, 0.58 to 0.64). Conclusions:. The predictive models did not reach the prespecified clinical utility threshold. Our models' inability to distinguish high-risk from low-risk patients is likely due to strict eligibility criteria and, therefore, homogeneous patient populations.

Published
2024
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2. Deep Surgical Site Infection after Fracture Has a Profound Effect on Functional Outcomes

Author

Ida Leah Gitajn, MD, MS, Paul M. Werth, PhD, Anthony R. Carlini, MS, Michael J. Bosse, MD, Joshua L. Gary, MD, Reza Firoozabadi, MD, MA, William Obremskey, MD, MPH, Todd O. McKinley, MD, Renan C. Castillo, PhD, Robert V. O’Toole, MD, and METRC, Edward R. Westrick, Eben A. Carroll, James Brett Goodman, Martha B. Holden, Anna N. Miller, Amanda Spraggs-Hughes, PhD, Michael L. Brennan, Paul Tornetta, III, Michael J. Weaver, Marilyn Heng, Patrick M. Osborn, Jessica C. Rivera, Clinton K. Murray, Joseph E. Kimmel, Charles Moon, Joseph R. Hsu, Madhav A. Karunakar, Laurence B. Kempton, Rachel B. Seymour, Stephen H. Sims, Christine Churchill, Rachel M. Reilly, Robert D. Zura, Cameron Howes, Hassan Mir, Emily A. Wagstrom, Brian Mullis, Jeffrey O. Anglen, Leilani S. Mullis, Karl D. Shively, Greg E. Gaski, Roman M. Natoli, Anthony Sorkin, Walter Virkus, Robert A. Hymes, Michael A. Holzman, A. Stephen Malekzadeh, Jeff E. Schulman, Cary C. Schwartzbach, Olivia C. Lee, Peter C. Krause, Massimo "Max" Morandi, Andrew Choo, John W. Munz, Sterling Boutte, Matthew C. Galpin, H. Michael Frisch, Adam M. Kaufman, C. Michael LeCroy, Christopher S. Smith, Alec C. Stall, Andrea Horne, Jason W. Nascone, Nathan N. O'Hara, Ebrahim Paryavi, Marcus F. Sciadini, Yasmin Degani, Andrea L. Howe, Roman Hayda, Andrew R. Evans, Debra L. Sietsema, Stanislaw P. Stawicki, Thomas Wojda, Michael J. Gardner, Julius A. Bishop, Saqib Rehman, Cyrus Caroom, Elizabeth Sheridan, Theodore Miclau, Saam Morshed, Thomas F. Higgins, Justin M. Haller, Paul E. Matuszewski, Arun Aneja, Raymond D. Wright, Jr., Patrick F. Bergin, Eldrin Bhanat, Matt L. Graves, John Morellato, Clay A. Spitler, David Teague, William Ertl, Jaimo Ahn, Patrick Hesketh, Gele B. Moloney, John C. Weinlein, Boris A. Zelle, Animesh Agarwal, Ravi A. Karia, Ashoke Sathy, Drew T. Sanders, David B. Weiss, Seth R. Yarboro, Veronica Lester-Ballard, Eric D. McVey, Arman Dagal, Michael Githens, Conor Kleweno, Julie Agel, Paul S. Whiting, Natasha M. Simske, Alexander B. Siy, Basem Attum, Eduardo Burgos, Vamshi Gajari, Andres Rodriguez-Buitrago, Manish Sethi, Rajesh R. Tummuru, Jean-Claude G. D'Alleyrand, Lauren E. Allen, Susan C. Collins, Yanjie Huang, and Tara J. Taylor

Subjects
Orthopedic surgery, RD701-811
Abstract

Background:. Fracture-related infection is one of the most challenging complications in orthopaedic trauma surgery. However, the effect of infection on functional and pain-related outcomes has not been well established. The aims of this study were to evaluate functional recovery for patients with fracture and a deep surgical site infection compared with patients with fracture without infection and to evaluate whether pain severity, social support, and preinjury mental health have a moderating effect on the magnitude and direction of the relationship between deep surgical site infection and functional recovery. Methods:. This is a secondary retrospective cohort study using prospectively collected data from the VANCO trial (Local Antibiotic Therapy to Reduce Infection After Operative Treatment of Fractures at High Risk of Infection) and the OXYGEN (Supplemental Perioperative Oxygen to Reduce Surgical Site Infection After High Energy Fracture Surgery) trial. In this study, 2,116 patients with tibial plateau, pilon, or calcaneal fractures at high risk for infection were included. Patients were divided into cohorts of patients who experienced a deep surgical site infection and those who did not. The primary outcome measure was the functional outcome using the Veterans RAND 12-Item Health Survey (VR-12). Results:. After controlling for covariates, deep surgical site infection was independently associated with functional outcome, with a 3.3-point reduction in the VR-12 Physical Component Score, and pain severity was independently associated with functional outcome, with a 2.5-point reduction in the VR-12 Physical Component Score. Furthermore, the Brief Pain Inventory pain severity demonstrated an important moderating effect on the relationship between infection and functional outcome. In patients with lower pain scores, infection had a large negative impact on functional outcome, whereas, in patients with higher pain scores, infection had no significant impact on functional outcome. Furthermore, the functional outcome in the entire cohort remains at only 61% of baseline. Conclusions:. This study documents the negative impact of postoperative infection on functional recovery after injury, as well as the novel finding of pain severity as an important moderating factor. This study emphasizes not only the importance of developing effective interventions designed to reduce postoperative infection, but also the role that factors that moderate pain severity plays in limiting recovery of physical function. Level of evidence:. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Published
2024
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3. Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures: A Randomized Clinical Trial

Author

Michael J. Bosse, Joanne Donnelly, Robert D. Zura, Heather A. Vallier, William T. Obremskey, Reza Firoozabadi, Yasmin Degani, Christine Churchill, Peter Z. Berger, Lauren C. Hill, Christina L. Boulton, Rachel B. Seymour, M. J. Crisco, Seth R. Yarboro, Jerald R. Westberg, Christopher M. McAndrew, Christina Riggsbee, Carrie Schoonover, Joshua L. Gary, Marcus F. Sciadini, Vamshi Gajari, Jason J. Halvorson, John C. Weinlein, Greg Osgood, Gele B. Moloney, Babar Shafiq, Sterling J. Boutte, Daniel O. Scharfstein, Olivia C. Lee, Thomas M. Large, Daniel Connelly, David L. Rothberg, Angela Mullins, Walter W Virkus, Drew Sanders, Christopher S. Smith, Cyrus Caroom, William M. Ricci, Animesh Agarwal, Vaishali Laljani, Thomas R Wojda, Medardo Maroto, Josie M. Hydrick, Lisa K. Schroder, Colette Hilliard, Joseph Kimmel, Boris A. Zelle, Stanislaw P Stawicki, Matthew L Graves, Mary A. Breslin, Ravi A. Karia, Susan C J Collins, Lauren E. Allen, James Brett Goodman, Debra L. Sietsema, Eric D. McVey, Anthony R. Carlini, Emily Wagstrom, Yanjie Huang, Patrick M. Osborn, Cara J. Rowe, Elizabeth Sheridan, Roman A. Hayda, Cameron Howes, Christopher T. LeBrun, Mary Zadnik, Laura S. Phieffer, Jessica C. Rivera, Andrew R. Evans, Sharon Haaser, Andrew M Choo, Greg E. Gaski, Justin M. Haller, Jeff E. Schulman, Jaslynn A.N. Cuff, J. Spence Reid, David Teague, Basem Attum, Tara J. Taylor, Cesar S. Molina, Julius A. Bishop, Peter C. Krause, Laurence B. Kempton, Timothy S. Achor, Colin V. Crickard, Lindsay E. Hickerson, Clay A. Spitler, Hassan R. Mir, Veronica Lester-Ballard, Michael L. Brennan, Ryan N Montalvo, Theodore T. Manson, Jason W. Nascone, Chinenye O. Nwachuku, Anna N. Miller, Rachel M. Reilly, Timothy Costales, A. Stephen Malekzadeh, Renan C. Castillo, Kathy Ringenbach, Paul S. Whiting, A. Alex Jahangir, Michael D. Holzman, Michael J. Gardner, Andres Rodriguez-Buitrago, Andrew N. Pollak, George V Russell, Gerald J. Lang, Massimo Max Morandi, Gerard P. Slobogean, John W. Munz, Brigham Au, Andrea Howe, Clinton K. Murray, Saqib Rehman, Ashoke K. Sathy, Alexander B. Siy, Daniel Mascarenhas, Adam M. Kaufman, Anthony T. Sorkin, Stephen H. Sims, Karen M. Trochez, Gabriela Gonzales, H. Michael Frisch, Manjari Joshi, Thomas F. Higgins, G Bradley Reahl, Roman M. Natoli, C. Michael Lecroy, William J.J. Ertl, Nathan N O'Hara, Madhav A. Karunakar, Patrick F. Bergin, Sandy Vang, Joseph R. Hsu, Martha B. Holden, Eduardo J. Burgos, Lolita Ramsey, David B. Weiss, Amanda Spraggs-Hughes, Clifford B. Jones, Mark D. Jenkins, Michael J. Weaver, Robert A. Hymes, David C. Goodspeed, Robert V O'Toole, and Dimitrius Marinos

Subjects
Adult, Male, medicine.medical_specialty, Time Factors, Intra-Articular Fractures, 030230 surgery, Pilon fracture, law.invention, 03 medical and health sciences, Fracture Fixation, Internal, 0302 clinical medicine, Randomized controlled trial, Double-Blind Method, law, Vancomycin, Post-hoc analysis, Fracture fixation, Surgical Wound Dehiscence, medicine, Infection control, Humans, Surgical Wound Infection, Prospective Studies, Gram-Positive Bacterial Infections, Probability, Wound dehiscence, business.industry, Absolute risk reduction, Middle Aged, medicine.disease, Surgery, Anti-Bacterial Agents, Tibial Fractures, 030220 oncology & carcinogenesis, Fractures, Ununited, Female, Powders, business, Gram-Negative Bacterial Infections, medicine.drug
Abstract

Importance Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist. Objective To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections. Design, Setting, and Participants This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers. Interventions A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder. Main Outcomes and Measures The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence. Results The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, –3.4%; 95% CI, –6.9% to 0.1%;P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, –3.7%; 95% CI, –6.7% to –0.8%;P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, –1.6% to 2.1%;P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections. Conclusions and Relevance Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin. Trial Registration ClinicalTrials.gov Identifier:NCT02227446

Published
2021

4. Free Vascularized Fibular Bone Grafting in the Management of Femoral Neck Nonunion in Patients Younger Than Fifty Years

Author

C. Michael Lecroy, James R. Urbaniak, Marco Rizzo, and Eunice E. Gunneson

Subjects
Adult, Male, medicine.medical_specialty, Time Factors, Adolescent, Bone disease, medicine.medical_treatment, Population, Nonunion, Dentistry, Bone grafting, Femoral Neck Fractures, medicine, Humans, Orthopedics and Sports Medicine, Bony Callus, Child, education, Femoral neck, education.field_of_study, Bone Transplantation, business.industry, Age Factors, Osteonecrosis, General Medicine, Middle Aged, medicine.disease, Arthroplasty, Surgery, Radiography, stomatognathic diseases, Outcome and Process Assessment, Health Care, medicine.anatomical_structure, Fibula, Fractures, Ununited, Orthopedic surgery, Female, business, Follow-Up Studies
Abstract

The incidence of nonunion and osteonecrosis after femoral neck fracture has been well documented. In older patients implant arthroplasty is well established as an acceptable treatment of these problems. However, in the younger population alternatives to implant arthroplasty are favored to preserve the femoral head. Surgical treatments for nonunion of the femoral neck include osteotomy, nonvascularized bone grafting, muscle-pedicle bone grafting, and vascularized bone grafting. The purpose of this study is to examine the results of free vascularized fibular grafting as a treatment of nonunion of the femoral neck in patients younger than fifty years.Twenty-two consecutive patients underwent vascularized bone grafting for nonunion of the femoral neck after failed internal fixation between 1984 and 1998. The mean age of the patients was 28.7 years. There were thirteen male and nine female patients. The mean interval between internal fixation and free vascularized fibular grafting was 18.3 months. The average follow-up to date is 84.7 months (range 29 to 195 months).Twenty of twenty-two nonunions healed. Two patients required an additional procedure to facilitate union; one patient had iliac crest bone grafting at four months postoperatively and another underwent muscle-pedicle grafting at six months postoperatively. The average time to union for all patients was 9.9 months (range 3 to 23 months). Progression of osteonecrosis of the femoral head occurred in thirteen patients. However, successful long-term salvage of the femoral head was achieved in twenty of twenty-two patients, with an average Harris hip score of 78.9. Four patients required hardware removal or exchange for intraarticular migration with no long-term clinical sequelae.Rates of complications, such as nonunion and osteonecrosis, after femoral neck fractures in young patients have been reported to be as high as 86 percent. Treatments such as osteotomy, muscle-pedicle bone grafting, nonvascularized bone grafting, and vascularized bone grafting have reported variable results. Based on the results reported in this study, vascularized fibular bone grafting compares favorably with a high union rate (91 percent initially, 100 percent after secondary procedures) and successful long-term salvage of the femoral head in 91 percent of the patients. Free vascularized fibular bone grafting represents a promising solution for this difficult problem.

Published
2002
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5. How surgeons make decisions when the evidence is inconclusive

Author

Prashanth Ina, Robert R.L. Gray, Gustavo Mantovani Ruggiero, David J. Rowland, Yoram Weil, M. R. de Vries, Renato M. Fricker, Georges Kohut, Antonio Barquet, Karl Josef Prommersberger, Takashi Sasaki, Eckart Schwab, Taco Gosens, Joseph M. Conflitti, David Ring, M. A. Aita, Ladislav Mica, Joseph A. Abboud, Michael Jones, Daniel Hernandez, Gregory L. DeSilva, Hal MccUtchan, Thomas W. Wright, Kendrick E. Lee, Marinis Pirpiris, Ian A. Harris, Marc F. Swiontkowski, Neil Wilson, Norah M. Harvey, Eric P. Hofmeister, Howard D. Routman, Lawrence Weiss, Nicholas L. Shortt, Jorge Rubio, Axel Jubel, John S. Taras, Gustavo Regazzi, Sergio L. Checchia, Jack Choueka, Jorge L. Orbay, Michael A. Baskies, Rolf Norlin, Vispi Jokhi, Todd E. Siff, Ashish S. Ranade, Lisa L. Lattanza, Jeff W. Johnson, Hans J. Kreder, Rozental, Cayón Cayón, Rajat Varma, Paul T. Appleton, Leonid I. Katolik, Asheesh Bedi, Filip Celestyn Dolatowski, Steve Kronlage, Paul M. Guidera, Elisabeth Prelog-Igler, David M. Kalainov, Charles L. Getz, Chunyan Jiang, Porcellini, A. Iossifidis, J Andrew I Trenholm, Frede Frihagen, K. Sprengel, Minos Tyllianakis, Steven J. McCabe, David Weiss, C. Taleb, Andrew P. Gutow, Sebastian Kluge, Jin Young Park, Michael R. Hausman, Paul A. Martineau, Michel P J Van Den Bekerom, W. A H Van Der Stappen, Thomas G. Stackhouse, Thomas Dienstknecht, Babst H. Reto, Jonathan L. Hobby, Iain McGraw, Tony Wanich, Augustus D. Mazzocca, Samir Sodha, J. Biert, Matthias Turina, Ines C. Lin, Daniel Rikli, Fischmeister Martin, Chad Manke, Roman Pfeifer, Lars C. Borris, M. Quell, Fabio Suarez, Daniel B. Whelan, John P. Evans, Michael Nancollas, Marco Rizzo, Lawrence S. Halperin, Carl Ekholm, David E. Tate, Steven J. Morgan, Betsy M. Nolan, F. J. Seibert, W. Arnnold Batson, Richard Barth, Brent Bamberger, A. B. Spoor, Seth D. Dodds, Jeffrey A. Greenberg, Victoria D. Knoll, Wade R. Smith, Michael D. McKee, Rolf W. Peters, Christopher J. Walsh, Jochen Fischer, Martin I. Boyer, Raymond Malcolm Smith, P. V. van Eerten, Philipp N. Streubel, Thomas B. Hughes, Milind Merchant, Peter J. L. Jebson, Bret C. Peterson, Theodoros H. Tosounidis, Luke S. Austin, David L. Nelson, M. R. Krijnen, K.J. Ponsen, Chris Wilson, Gladys Cecilia Zambrano Caro, Daniel B. Polatsch, Matthew D. Budge, Reza Omid, Louis W. Catalano, Emil H. Schemitsch, Roy G. LiemKulick, Richard S. Page, Michael W. Kessler, Donald Endrizzi, Anna N. Miller, Jorge G. Boretto, Peter Kloen, J. Michael Wiater, Fidel Ernesto, German Ricardo Hernandez, Leon S. Benson, Peter J. Evans, John Howlett, Verhofstad, Michael J. Behrman, A. L. Van Der Zwan, Ryan P. Calfee, Robert D. Zura, Leon Elmans, Anica Eschler, D. Kaplan, Richard S. Gilbert, F. Thomas, Johannes M. Rueger, Eon K. Shin, Sam Moghtaderi, Julie E. Adams, Jaimo Ahn, D. F. P. van Deurzen, Ralf Nyszkiewicz, W. Jaap Willems, Huub Van Der Heide, Aida Garcia, L.M.S.J. Poelhekke, Philip E. Blazar, Daniel C. Wascher, Luis Antonio Buendia, S. Prashanth, Peter Krause, Maarten W.G.A. Bronkhorst, Noah D. Weiss, Kyle J. Jeray, Ronald Liem, Andrew L. Terrono, Niels W. L. Schep, Sander Sprujt, Ryan Klinefelter, Robert Haverlag, Steven Beldner, Nikolaos G. Lasanianos, Ramon De Bedout, Rudolf W. Poolman, I. J.V. Kleinlugtenbelt, Alexander Marcus, Greg Merrell, Naquira Escobar Luis Felipe, Kimberlly S. Chhor, Jeffrey Yao, Lob Guenter, Parag Melvanki, Arie B. van Vugt, Francisco Lopez-Gonzalez, Craig Lomita, Saul Kaplan, Matt Mormino, Theresa O Wyrick, Gregory J. Della Rocca, C. Noel Henley, Edgardo Ramos Maza, Christopher B. Wall, Fred Baumgaertel, Roger P. van Riet, Sebastian Rodriguez-Elizalde, Stuart M. Hilliard, George S. Athwal, Peter V. Giannoudis, Angela A. Wang, Tamir Pritsch, John A. McAuliffe, Robert J. Feibel, Timothy Omara, Paul Levin, Jonathan Rosenfeld, Michael J. Prayson, Mark E. Baratz, R. Bryan Benafield, Christian Perrotto, George L. Thomas, Punita V. Solanki, George M. Kontakis, Robert Wagenmakers, Charles A. Goldfarb, Andrew H. Schmidt, Abhay Shrivastava, Mark D. Lazarus, Frederico C M Vallim, L. Marsh, Keith A. Segalman, H. Goost, Peter R. Brink, Michael W. Grafe, Jonathan P. Braman, April D. Armstrong, Charles Cornell, Thomas A. DeCoster, Daphne M. Beingessner, Neal C. Chen, Charalampos Zalavras, M. A J Van De Sande, Jennifer L. Giuffre, Thuan V. Ly, Georg M. Huemer, Vani J. Sabesan, Rodrigo Pesantez, Kevin Eng, A. Lee Osterman, Darren S. Drosdowech, Michael Moskal, B. Van Den, Nigel Rossiter, Michael Baumgaertner, Christian Heiss, James F. Kellam, P. C. Fuchs, Matej Kastelec, David J. Hak, Karel Chivers, Amy L. Ladd, Reid A. Abrams, Bob Arciero, Russell Shatford, Toni M. McLaurin, George S.M. Dyer, Ralph M. Costanzo, Frank L. Walter, Craig M. Torosian, Koroush Kabir, Timothy G. Havenhill, Brian L. Badman, Joachim P. Overbeck, Charles Metzger, Vishwanath M. Iyer, Annette K B Wikerøy, Carlos Henrique Fernandes, Jay Pomerance, Patrick T. McCulloch, Megan M. Wood, Richard Jenkinson, Brian J. Cross, Christos Garnavos, Marcus Lehnhardt, Ashok K. Shyam, Michael LeCroy, Abhijeet L. Wahegaonkar, Carrie R. Swigart, Lisa Taitsman, Vasileios S. Nikolaou, Gerald R. Williams, J. H. Peters, Sergio Rowinski, William Dias Belangero, Ibrahim Ibrahim, Jeremy A. Hall, Charles Cassidy, Mahmoud I. Abdel-Ghany, Michiel G.J.S. Hageman, M. Jason Palmer, Joseph P A M Vroemen, Frank J. P. Beeres, Alberto Pérez Castillo, Gustavo Borges Laurindo De Azevedo, Martin Richardson, Wolfgang Baer, Shep Hurwit, J. V. Clarke, Robert Tashijan, Scott F. M. Duncan, Thierry G. Guitton, Steven J. Rhemrev, J. Wolkenfelt, Richard Wallensten, Neil Saran, Brett D. Crist, J. Carel Goslings, Qiugen Wang, Francisco Javier Aguilar Sierra, Leonardo Alves De Mendonca, Paula M. Hasenboehler, Sanjeev Kakar, Grant E. Garrigues, Leonardo Rocha, Joel Murachovsky, Vidyadhar Telang, Edward J. Harvey, Richard Buckley, Jose A. Ortiz, Schandelmaier, Edward K. Rodriguez, Konul Erol, H. J. Helling, Nikolaos K. Kanakaris, Jeffry T. Watson, Desirae M. McKee, Graduate School, Orthopedic Surgery and Sports Medicine, AMS - Amsterdam Movement Sciences, Surgery, Other Research, and Other departments

Subjects
Male, medicine.medical_specialty, Decision Making, Alternative medicine, Likert scale, medicine, Humans, Orthopedics and Sports Medicine, Somewhat Important, Reimbursement, Social influence, Evidence-Based Medicine, business.industry, Mentors, Perspective (graphical), Evidence-based medicine, Hand, Surgery, Orthopedics, Family medicine, Practice Guidelines as Topic, Female, Clinical Competence, business, Null hypothesis
Abstract

Purpose To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. Methods We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." Results According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most important factors when evidence shows no difference between 2 surgeries were "fewer complications," "quicker recovery," "burns fewer bridges," "works in my hands" and "familiarity with the procedure." Europeans rated "works in my hands" and "cheapest/most resourceful" of significantly greater importance and "what others are doing," "highest reimbursement," and "shorter procedure" of significantly lower importance than surgeons in the United States. Observers with fewer than 10 years in independent practice rated "what my mentor taught me," "what others are doing" and "highest reimbursement" of significantly lower importance compared to observers with 10 or more years in independent practice. Conclusions Surgeons deciding between 2 treatment options, when the evidence is inconclusive, fall back to factors that relate to their perspective and reflect their culture and circumstances, more so than factors related to the patient's perspective, although this may be different for younger surgeons. Clinical relevance Hand surgeons might benefit from consensus fallback preferences when evidence is inconclusive. It is possible that falling back to personal comfort makes us vulnerable to unhelpful commercial and societal influences.

Published
2013

6. Change over time of SF-36 functional outcomes for operatively treated unstable ankle fractures

Author

William T. Obremskey, William L. Craig, Robin Driver, Douglas R. Dirschl, C. Michael Lecroy, and James D. Crowther

Subjects
Change over time, Adult, Joint Instability, Male, medicine.medical_specialty, Time Factors, SF-36, Adolescent, Chirurgie orthopedique, Joint Dislocations, Fracture Fixation, Internal, Fractures, Bone, Injury Severity Score, Surveys and Questionnaires, Medicine, Humans, Orthopedics and Sports Medicine, Ankle Injuries, Range of Motion, Articular, Aged, Probability, Aged, 80 and over, Fracture Healing, Osteosynthesis, business.industry, General Medicine, Recovery of Function, Middle Aged, Functional recovery, Prognosis, Surgery, medicine.anatomical_structure, Treatment Outcome, Extremity fractures, Orthopedic surgery, Physical therapy, Female, Ankle, Patient Participation, business, Follow-Up Studies
Abstract

Ankle fractures are one of the most common operatively treated lower extremity fractures. Several studies indicate that patients often have residual effects after this injury. The purpose of this study is to use the SF-36 questionnaire at two times to assess patients' functional recovery and residual effects after operative stabilization of an unstable ankle fracture.Twenty adult patients with an isolated unstable ankle fracture (OTA 44B/C) who had operative stabilization completed an SF-36 questionnaire when they were released from orthopaedic follow-up at approximately four months from injury. These same patients again completed the SF-36 at a longer follow-up, twenty months on average. Both SF-36 scores were compared with U.S. population norms.Level II Community Hospital.Internal fixation of unstable ankle fractures.SF-36 questionnaire.Patients had significant improvement (p0.5) in all domains of the SF-36 questionnaire at the later follow-up, except for general health, which was unchanged. Patients still had significant differences in SF-36 scores compared with the U.S. population at the time of release from routine follow-up. The scores of all the domains of the SF-36 at the later follow-up were not significantly different from U.S. population norms except for the domain of physical functioning.This study indicates that patients have significant improvement in functional outcome after release from orthopaedic follow-up but have a residual physical effect at twenty months after injury. These data are important to guide a patient's expectations after this injury and are also important in considering medicolegal and workers' compensation issues. Patients continue to have improvement in function after we have routinely released them from orthopaedic follow-up. Maximal medical improvement appears to be longer than four months from this injury.

Published
2002

7. Approach to the polytraumatized patient with musculoskeletal injuries

Author

C. Michael LeCroy, Michael A. Dube, and Clifford H. Turen

Subjects
medicine.medical_specialty, Resuscitation, External Fixators, medicine.medical_treatment, External fixation, Fractures, Bone, Fracture Fixation, Risk Factors, Intervention (counseling), medicine, Trauma team, Humans, Orthopedics and Sports Medicine, Blood Transfusion, Orthopedic Procedures, Intensive care medicine, Pelvic Bones, Lung, Musculoskeletal System, Physical Examination, Early Ambulation, Neurologic Examination, Patient Care Team, business.industry, Multiple Trauma, Respiration, Pelvic trauma, Neurologic injury, Treatment Outcome, Orthopedic surgery, Blood Circulation, Physical therapy, Fluid Therapy, Surgery, Airway, business, Attitude to Health
Abstract

The management of the multiply injured patient is a challenge for even experienced clinicians. Because many community hospitals lack a dedicated trauma team, it is often the orthopaedic surgeon who will direct treatment. Therefore, the orthopaedic surgeon must have an understanding of established guidelines for the evaluation, resuscitation, and care of the severely injured patient. Initial evaluation encompasses assessment and intervention for airway, breathing, circulation, disability (neurologic injury), and environmental and exposure considerations. Resuscitation requires not only administration of fluids, blood, and blood products but also emergent management of pelvic trauma and stabilization of long-bone fractures. Judicious early use of anterior pelvic external fixation can be lifesaving in many cases. The secondary survey, which is often neglected, must incorporate a thorough physical evaluation. Although the method of fracture stabilization is still controversial, most clinicians agree that early fixation offers many benefits, including early mobilization, improved pulmonary toilet, decreased cardiovascular risk, and improved psychological wellbeing. Without an understanding of the complexities of the multiply injured patient, delays in the diagnosis and treatment of a patientOs injuries are likely to adversely affect outcome. J Am Acad Orthop Surg 1999;7:154-165

Published
1999

8. Chondral delamination of the knee in soccer players

Author

Andrew S. Levy, William E. Garrett, Sean Sculley, Michael LeCroy, and John Lohnes

Subjects
musculoskeletal diseases, Chondropathy, Adult, Cartilage, Articular, Male, medicine.medical_specialty, Fractures, Cartilage, Time Factors, Population, Physical Therapy, Sports Therapy and Rehabilitation, Physical examination, Knee Injuries, 03 medical and health sciences, Arthroscopy, Fractures, Bone, 0302 clinical medicine, Arthropathy, Osteoarthritis, Soccer, medicine, Autologous transplantation, Humans, Orthopedics and Sports Medicine, Femur, education, Physical Examination, Retrospective Studies, 030222 orthopedics, education.field_of_study, Crepitus, medicine.diagnostic_test, business.industry, Articular cartilage injuries, General Medicine, 030229 sport sciences, Exudates and Transudates, Patella, medicine.disease, Arthralgia, Magnetic Resonance Imaging, Surgery, Athletic Injuries, Female, medicine.symptom, business, human activities, Follow-Up Studies
Abstract

This study reports on the diagnosis and treatment of chondral delamination in the knees of soccer players. The authors attempted to provide a clinical standard for comparison with emerging cartilage repair techniques. Twenty-three consecutive chondral fractures in a ho mogeneous population of athletes were evaluated us ing physical examination, magnetic resonance imag ing, and arthroscopic examination. All knees were treated with debridement to a stable border and re moval of the calcified cartilage base. Results were graded using the scoring system advocated by propo nents of chondral transplant. All patients reported pain that limited soccer activities. Effusions occurred in 48%, joint line tenderness in 33%, and crepitus in 19% of the knees. Results from magnetic resonance imag ing correlated with arthroscopic examination in 21 % of the knees. Arthroscopic examinations revealed lesions on the medial femoral condyle in eight patients, the patella in six, the lateral femoral condyle in six, and the trochlea in three. Athletes returned to play at an aver age of 10.8 weeks. Repeat arthroscopic procedures in eight cases revealed fibrocartilage at the initial site. There were 6 excellent, 9 good, 0 fair, and 0 poor results at their 1-year followup examinations (15 knees). The definitive diagnosis of chondral delamina tion relies on a thorough arthroscopic probing of the articular surface. The early functional results of this treatment compare favorably with the autologous transplantation technique. Caution, however, is recom mended when treating articular cartilage injuries be cause no long-term data exists on whether any treat ment modality can prevent the development of degenerative joint disease.

Published
1996

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